chapter 12 alternatives to hospital care - nice

National Institute for Health and Care Excellence

Final

Chapter 12 Alternatives to hospital care Emergency and acute medical care in over 16s: service delivery and organisation

NICE guideline 82

Developed by the National Guideline Centre, hosted by the Royal College of Physicians

December 2017

Emergency and acute medical care Contents

Chapter 12 Alternatives to hospital care

1

Emergency and acute medical care

Disclaimer Healthcare professionals are expected to take NICE clinical guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and/or their guardian or carer.

Copyright © NICE 2017. All rights reserved. Subject to Notice of rights.

Chapter 12 Alternatives to hospital care

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Chapter 12 Alternatives to hospital care 4

Contents 12 Alternatives to hospital care ................................................................................................. 5

12.1 Introduction .......................................................................................................................... 5

12.2 Review question: Does community-based intermediate care improve outcomes compared with hospital care? .............................................................................................. 5

12.2.1 Definitions of the different alternatives to hospital care evaluated in this review ....................................................................................................................... 6

12.3 Clinical evidence .................................................................................................................... 9

12.3.1 Individual patient data (IPD) analysis ..................................................................... 10

12.3.2 Summary of included studies ................................................................................. 10

12.4 Economic evidence ............................................................................................................. 34

12.5 Evidence statements ........................................................................................................... 45

12.5.1 Clinical .................................................................................................................... 45

12.5.2 Economic ................................................................................................................ 46

12.6 Recommendations and link to evidence ............................................................................. 48

References .................................................................................................................................. 54

Appendices ................................................................................................................................. 77

Appendix A: Review protocol ........................................................................................................ 77

Appendix B: Clinical article selection ............................................................................................ 79

Appendix C: Forest plots ............................................................................................................... 80

Appendix D: Clinical evidence tables ............................................................................................. 91

Appendix E: Economic evidence tables ...................................................................................... 138

Appendix F: GRADE tables .......................................................................................................... 167

Appendix G: Excluded clinical studies ......................................................................................... 176

Appendix H: Excluded economic studies ..................................................................................... 184



12 Alternatives to hospital care

12.1 Introduction

There is an increasing evidence base to support the treatment of some acute medical illnesses using ambulatory care, that is, where patients receive treatment whilst staying in their own home or care home after a clinical assessment. In addition, there is an increasing recognition that not all patients have a good experience of hospital bed based care, and that treatment in the usual place of residence would be preferable if safe to do so with an appropriate care model in place.

Whilst there are policy statements from national bodies that are supportive of greater provision of alternatives to hospital care for acute medical illness, there is current uncertainty over the most clinically and cost-effective models of alternatives to hospital care.

12.2 Review question: Does community-based intermediate care improve outcomes compared with hospital care?

For full details see review protocol in Appendix A.

Table 1: PICO characteristics of review question

Population Adults and young people (16 years and over) with a suspected or confirmed AME or at risk of an AME.

Interventions Alternatives to hospital care including the following:

• Hospital at home including care at home led by

o Secondary care physicians

o Primary care (GP and nurse)

o Both

• Step up/down care

• Rapid response schemes

• Virtual wards

For definitions of each intervention please refer section 1.2.1.

Strata:

• Early discharge

• Admission avoidance

Comparison Hospital-based care/services.

Outcomes • Mortality (CRITICAL)

• Avoidable adverse events (CRITICAL)

• Quality of life (CRITICAL)

• Patient satisfaction (CRITICAL)

• Length of hospital stay (IMPORTANT)

• Length of stay in programme (IMPORTANT)

• Number of presentations to Emergency Department (IMPORTANT)

• Number of admissions to hospital (CRITICAL)

• Number of GP presentations (IMPORTANT)

• Readmission (up to 30 days since admission ) (IMPORTANT)

Study design Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified.



12.2.1 Definitions of the different alternatives to hospital care evaluated in this review

12.2.1.1 Intermediate Care (IC)

The development of IC services was set out in 2001 within the National Service Framework for Older People. The aims of IC were stated as being to:

• promote faster recovery from illness,

• support timely discharge from hospital,

• prevent unnecessary acute hospital admission,

• maximise independent living.

The expectation was of multi-agency working based on comprehensive geriatric assessment, with short-term interventions to enable users to remain or resume living at home.

Definition of intermediate care

The definition of intermediate care provided in the Department of Health paper ‘Intermediate Care - Halfway Home’80 was used; “a range of integrated services to promote faster recovery from illness, prevent unnecessary acute hospital admission and premature admission to long-term residential care, support timely discharge from hospital and maximise independent living”. The guidance makes clear that intermediate care services involve multi-disciplinary team working. Although homecare reablement is included within intermediate care services in some areas, services that do not have a clinical health element are not included.

The National Intermediate Care Audit demonstrates that intermediate care does increase the likelihood of returning home, improve the ability to perform activities of daily living and also increases the achievement of person specific goals. However, there is significant variation in delivery between regions throughout England and unfortunately at present it is not making a difference to the whole-system due to the lack of capacity within the service.214

Classification of Intermediate Care Schemes (as taken from the Department of Health ‘Audit of Intermediate Care’, 2008)

i. Home from hospital

A home from hospital scheme generally aims to provide short-term post-discharge care at a more intensive level than would normally be provided by professionals such as District Nursing. Home from hospital schemes are generally delivered in the user’s own home and led by nursing staff, sometimes with input from medical and allied health professionals.

ii. Rapid response schemes

Rapid response schemes generally aim to support a user in their own home or other location either as a means of preventing admission or as a means of facilitating discharge from the acute hospital sector. Usually led by either a nurse or allied health professional, rapid response schemes can cover a wide range of interventions including administration of intravenous therapies, peg tube and catheter replacement, crisis psychiatric care and provide enhanced care to palliative care patients.

iii. Step up/down schemes

Step up/down schemes usually provide care in a setting other than an acute hospital and this can include a residential or, more usually, a nursing home. Time limited in nature, these schemes aim to either prevent admission to hospital, or aid in the discharge and transfer back home from hospital. Step up/down schemes can be aimed at similar patients to both rapid response and rehabilitation.



However, normally the users require more intensive therapy or continuous monitoring than could be provided in their own home.

iv. Rehabilitation schemes

The delivery of community rehabilitation is cognisant with the role of intermediate care which has been promoted by the Department of Health. Rehabilitation is defined as “a process aiming to restore personal autonomy to those aspects of daily life considered most relevant by patients and service users, and their family carers” (Kings Fund, 1998). It is believed that this form of care will reduce the burden on the NHS through the promotion of independence.

Rehabilitation schemes usually provide time limited therapy for patients who require on-going allied health support (generally physiotherapy or occupational therapy) to regain maximum independence. Users of rehabilitation schemes will often have sustained some form of fracture and may also have undergone surgery. Rehabilitation schemes can be delivered by a multi-disciplinary team, but are often led by physiotherapists and/or occupational therapists. These schemes may be longer-term in nature than other types of schemes.

Rehabilitation is defined as the process of restoration of skills by a person who has had an illness or injury so as to regain maximum self-sufficiency and function in a normal or as near normal manner as possible. Rehabilitation is a process aiming to restore personal autonomy to those aspects of daily life considered most relevant to patients, service users and their carers. It can be delivered at a community hospital, residential home or within a patient’s own home.

v. Stroke schemes

Stroke schemes tend to provide a high level of support for those patients who have undergone a cerebrovascular accident (CVA) and to provide a high level of rehabilitation, usually in the users own home, to assist them in gaining an increased level of independence. Stroke schemes can be delivered by a multi-disciplinary team that includes medical, nursing, allied health and social work, and also can include the assistance of generic rehabilitation assistants (covering physiotherapy and occupational therapy). These schemes may be longer-term in nature than other types of schemes.

vi. Community hospital schemes

Community hospital schemes usually provide acute hospital ward type care, but generally under the management of GPs rather than consultants. Community hospital schemes can provide nursing, rehabilitation or step up/down type care and are generally aimed at those users who require a high level of supervision or the administration of medicines or interventions which would not be suitable for a nursing home or a users’ own home setting.

vii. Miscellaneous schemes

These schemes included a range of schemes which did not directly fit into one of the classifications previously described. They included an ED assessment team, a twilight nursing team, and a long-term behaviour support team. It could be debated whether these schemes can truly be classified as intermediate.



Within the Intermediate tier there is distinction between:

viii. Enabling Homecare - which provides the fundamental building block of a care system where optimised independence and choice is a primary goal. This is aimed at ensuring such skills are maintained by the individual and will be found across the whole care system including any homecare delivered as part of an intermediate tier.

ix. Reablement - for people with poor physical or mental health or disability where there is potential to improve independence and choice by learning or re-learning the skills necessary for daily living; and:

When referring to reablement in this context it is also helpful to distinguish between:

• Intake reablement - where all new referrals to adult social services (in particular home care) are considered for reablement; and

• Targeted reablement - where referrals to reablement are received from specific sources, normally hospital discharge or to prevent hospital admission.

x. Hospital-at-home care is generally defined as the community based provision of services usually associated with acute inpatient care.

“Hospital-at-home” programs are defined by the provision, in patients’ own homes and for a limited period, of a specific service that requires active participation by health care professionals. The care tends to be multidisciplinary and may include technical services, such as intravenous services.

Many disparate models have been developed under the hospital-at-home label, leading to difficulties in evaluating their effectiveness.

Key features of the Johns Hopkins “hospital-at-home” model:

• A substitutive model providing hospital-level care for patients living in a specified geographic catchment area delineated by 30 minute travel time.

• Eligible patients are those with certain acute illnesses that require hospital-level care who also meet previously validated medical eligibility criteria.

• Robust input from physicians (at least daily visits and 24 hour coverage) and nurses (initial continuous nursing care following by intermittent visits and 24 hour coverage).



• Patient retains inpatient status and the hospital or health system retains responsibility for the acute care episode.

• Care is provided in a coordinated manner similar to that in an inpatient ward.

xi. The Virtual Ward

Virtual wards are a form of preventive hospital-at-home for patients at high predicted risk of unplanned hospital admission.

A model of home-based coordinated care with the aim of reducing hospital admissions in a relatively low-cost manner. The "virtual ward" program provides multidisciplinary case management services to people who have been identified, using a predictive model, as high risks for future emergency hospitalisation. Virtual wards use the systems, staffing and daily routine of a hospital ward to deliver preventive care to patients in their own homes. The Virtual Wards work just like a hospital ward, using the same staffing, systems and daily routines, except that the people being cared for stay in their own homes throughout.

Virtual wards seek to improve integration through a number of strategies, including a shared record, multidisciplinary team meetings ("ward rounds") and an automated alert system for informing virtual ward staff when a patient accesses another care service, such as attending local ED. Another strategy for promoting integration was to include a social worker as a core member of the virtual ward staff. In this regard, it could be argued that virtual wards are an adaptation of the public health model of chronic disease management described by Kendall and colleagues but rather than integrating health and education, virtual wards instead aim to provide patients with a well organised and coordinated service that crosses the health care and social care sectors.

Community matrons:

Community matrons are highly experienced senior nurses who work closely with patients in the community to provide, plan and organise their care. They mainly work with those with a serious long term or complex range of conditions. They therefore have an important role in the management of chronic long-term disease and multi-morbidity. These patients account a large consumption of NHS resources. Clear leadership, guidance and communication between the many services which are involved in the patient care is important to avoid mishaps. Therefore, the community matron is ideally placed to deliver this with the appropriate training and support. This review will determine if increasing the remit of community matrons and increasing the number of locations where community matrons can be accessed improves patient outcomes.

12.3 Clinical evidence

We searched for systematic reviews and randomised trials comparing the effectiveness of alternatives to hospital care (hospital at home, step-up/down care, rapid response schemes and virtual wards) with hospital care to improve outcomes for patients.

Thirty four randomised controlled trials were identified that compared alternatives to hospital care with hospital care. We identified 3 Cochrane reviews evaluating different alternatives to hospital care. All the reviews were assessed for relevance to the review protocol and methodology and were adapted and updated as part of this systematic review. The classification of interventions of the studies included in the Cochrane reviews did not match the definitions of interventions pre-specified by the guideline committee. We re-classified the studies included in the Cochrane reviews according to the definitions of the interventions (see section 12.2.1). Data for the studies presented in the Cochrane reviews has been included in the analysis. We have updated the Cochrane reviews with randomised controlled trials found from the search.



The studies have been classified in 2 strata- admission avoidance and early discharge. Admission avoidance is a service that provides active treatment by health care professionals outside hospital for a condition that otherwise would require acute hospital in-patient admission. Early discharge is a service that provides active treatment by health care professionals outside hospital for a condition that otherwise would require continued acute hospital in-patient care.

Within each strata, the studies have been grouped according to the type of service provided: hospital at home led by primary care, hospital at home led by secondary care, hospital at home led by primary and secondary care, step-up/down care and virtual wards.

12.3.1 Individual patient data (IPD) analysis

Two Cochrane reviews that met the protocol criteria for the alternatives to hospital care review (1 in the strata for early discharge and 1in the strata for admission avoidance) presented IPD analysis as well as RCT level meta-analysis.

Details of analyses presented in both Cochrane reviews are:

• Review strata 1 –Admission avoidance: Cochrane review on hospital at home admission avoidance. The review includes 10 trials.

o 4 trials were included in the IPD analysis (hazard ratios and log hazard ratios presented for 2 of our protocol outcomes; mortality and admissions).

o All 10 trials were included in the RCT meta-analysis. The RCT meta-analyses included RCT data from the 4 trials included in the IPD meta-analysis.

• Review strata 2- Early discharge: Cochrane review on hospital at home early discharge. The review includes 26 trials.

o 13 trials were included in the IPD analysis (hazard ratios and log hazard ratios presented for 2 of our protocol outcomes; mortality and admissions).

o All 26 trials were included in the RCT meta-analysis. The RCT meta-analyses included RCT data from the 13 trials included in the IPD meta-analysis.

The results of the IPD analysis have been presented as part of this evidence review (see section D.3, Appendix D).

See also the study selection flow chart in Appendix B, study evidence tables in Appendix E, forest plots in Appendix D, GRADE tables in Appendix G and excluded studies list in Appendix H.

12.3.2 Summary of included studies

Following is a summary of the number of studies included for each of the interventions:

• Hospital at home (led by primary care): o Number of studies identified in Cochrane reviews: 10. o Number of studies identified from search: 4.

• Hospital at home (led by secondary care): o Number of studies identified in Cochrane reviews: 4. o Number of studies identified from search: 3.

• Hospital at home (led by primary and secondary care): o Number of studies identified in Cochrane reviews: 7. o Number of studies identified from search: 1.

• Virtual wards: o Number of studies identified in Cochrane reviews: 0. o Number of studies identified from search: 2.

• Step up/down care:



o Number of studies identified in Cochrane reviews: 0. o Number of studies identified from search: 5

See Table 2 below for details of the PICO characteristics of the studies included in the review.

Table 2: Summary of studies included in the review

Study Intervention and comparison Population Outcomes Comments

Cochrane reviews

Jeppesen 2012160

Hospital at home for acute exacerbations of chronic obstructive pulmonary disease (COPD).

-

Randomised controlled trials comparing home versus hospital acre treatment for acute exacerbation of COPD.

Patients presenting to the emergency department with an exacerbation of their COPD. Studies must not have recruited patients for whom treatment at home is usually not viewed as an responsible option (for example, patients with an impaired level of consciousness, acute confusion, acute changes on the radiograph or electrocardiogram, arterial pH less than 7.35, concomitant medical conditions).

Mortality, readmission rates, health related quality of life, lung function and direct costs.

Eight RCTs in Cochrane review, of which 7 studies included in our evidence review One study Nissen 2007 not included as study not in English.

Shepperd 2008271

Hospital at home admission avoidance.

Randomised controlled trials comparing admission avoidance hospital at home with acute hospital in-patient care.

Patients aged 18 years and over. The admission avoidance hospital at home interventions may admit patients directly from the community thereby avoiding physical contact with the hospital, or may admit from the emergency room.

Mortality, admissions, functional ability, quality of life, cognitive ability, patient satisfaction and costs.

Ten RCTs in Cochrane review , of which 8 RCTs included in our review. 2 RCTs excluded- Nicholson 2001- cost data only, Tibaldi 2004- no relevant outcomes .

Shepperd 2009273

Hospital at home early discharge.

Randomised controlled trials comparing early discharge hospital at home with acute hospital in-patient

Patients aged 18 years and over. Evaluations of obstetric, paediatric and mental health hospital at home schemes are excluded from this

Mortality, readmission rates, satisfaction, destination at follow-up and cost savings

Twenty six RCTs in Cochrane review. (6/26 studies included our evidence review)




care. review.

Hospital at Home (Primary Care)

Rich 1993241

RCT

Hospital at home (extensive discharge planning).

Team: nurse-led.

Versus

Control group: usual care after discharge (hospital services as required).

Adults (n=98) >70 years, with congestive heart failure. Washington University, USA.

Readmission (90 days), length of stay.

Not in Cochrane review.

EARLY DISCHARGE

Utens 2012300

Utens 2013302

Utens 2014303

RCT

Hospital from home (early discharge)

Team: community nurses.

Versus

Control group: usual hospital care.

Adults (n=139) >40 years, admitted for exacerbation of COPD.

Admissions, quality of life, mortality, patient satisfaction and carer stress.


Follow up for 3 months.

EARLY DISCHARGE

Corwin 200566

RCT

Hospital at home

Team: GP or community GP and community care nurses.

Versus

Control group: hospital administration of antibiotics.

Adults (n=200) >16 years of age, with clinical signs of cellulitis or failure of oral antibiotics.

Readmission (within 4 weeks), length of stay and satisfaction.

Included in Cochrane review.

Hospital at home admission avoidance. ADMISSION AVOIDANCE

Cotton 200067

RCT

Hospital at home (early discharge)

Team: specialist respiratory nurses, GP.

Versus

Control: discharged after usual care.

Adults (n=81) exacerbation of COPD.

Readmissions (within 60 days), mortality.

Included in Cochrane review.

Hospital at home early discharge. Hospital at home for acute exacerbations of chronic obstructive pulmonary disease (COPD). EARLY DISCHARGE

Hernandez 2003141

RCT


Team: GP-led, respiratory nurse.

Versus

Adults (n=222) with exacerbations of chronic COPD.

Mortality, presentations to ED, readmissions (8 weeks), length of stay, quality of life and patient

Included in Cochrane review

Hospital at home for acute exacerbations of chronic obstructive pulmonary.




Control group: normal discharge after usual hospital care.

satisfaction. EARLY DISCHARGE

Ojoo 2002222

RCT

Hospital at home

Team: outreach nurses.

Versus

Control group: inpatient care.

Adults (n= 60) >18 years, with an acute exacerbation of COPD.

Readmissions (3 months), mortality, quality of life, patient satisfaction and carer satisfaction.

Included in Cochrane review:

Hospital at home early discharge. Hospital at home for acute exacerbations of chronic obstructive pulmonary. EARLY DISCHARGE

Richards 2005242

RCT

Hospital at home

Team: GP and primary care nurses.

Versus

Control group: hospital management.

Adults (n=55) with mild to moderately severe pneumonia.

Readmission (6 weeks), quality of life and adverse events.



ADMISSION AVOIDANCE

Shepperd 1998265

Shepperd 1998268

RCT

Hospital at home

Team: nurse-led, physiotherapist, occupational therapist, pathology, SALT. GPs held responsibility.

Versus

Control group: inpatient hospital care.

Adults (n=532) recovering from surgery mainly but elderly medical and COPD patients also (table 6&7); outcomes for medical elderly patients reported only.

Readmission (3 months), mortality, quality of life and carer stress.

Included in Cochrane review: Hospital at home early discharge.

EARLY DISCHARGE

Talcott 2011 286

RCT

USA

Home treatment:

Supervised by the patients treating physician with additional assistance available from the research team. Patients at home were required to measure their temperature and blood pressure at least 4 times daily. They were examined by a home care nurse

n=117

Adult outpatients with post chemotherapy fever and neutropenia (absolute neutrophil count less than 500µl) that persisted after at least 24 hours.

Mortality and hospital re-admission.

Admission avoidance




who used a written protocol and was instructed to contact the primary physician if abnormal findings occurred. In addition, a physician examined each home care patient 2 to 4 days after discharge, at least weekly thereafter. Outpatients were readmitted to the hospital whenever a physician felt the patient’s condition warranted it, if the patient requested or it proved infeasible to administer the prescribed antibiotics.

Control:

Continued inpatient antibiotic therapy.

Wilson 1999312

Wilson 2002314

Wilson 2003313

RCT

Hospital at home

Team: nurse-led, physiotherapist, occupational therapists, health workers. GPs retain responsibility.

Versus

Control group: hospital care.

Adults (n=199) with an acute condition.

Mortality and readmissions (3 months).



ADMISSION AVOIDANCE

Hospital at Home (Secondary care)

Ince 2014154

RCT

Turkey

Home monitoring group.

After a median of 12 hours patients discharged from hospital and visited on 2nd, 3rd and 5th days by staff nurse. Patients discharged with an IV port and basic instructions for the maintenance of the port. All patients

Patients aged >18 years with a diagnosis of mild non-alcoholic acute intestinal pancreatitis.

30 day hospital re-admission.


EARLY DISCHARGE




were visited in their homes twice a day by an experienced nurse and all information transferred back to the attending physician. Patients given phone numbers of 2 physicians as emergency contacts.

Versus

Hospital group – treatment in hospital.

Mendoza 2009202

RCT

Hospital at Home (seen daily by specialist nurse and physician; from hospital).

Versus

Inpatient hospital care.

Adults (n=80) >65 years of age with decompensated heart failure were recruited from Emergency Department of Spanish University Hospital.

Mortality, readmission (for HF within 1 year follow-up), length of stay and quality of life.



ADMISSION AVOIDANCE

Patel 2008229

RCT

Hospital at Home (seen by specialist nurse at home; access to cardiologist consultant via phone).

Versus

Inpatient hospital care.

Adults (n=31)with a mean age of 77 years, presenting with deteriorating chronic heart failure were recruited from

Swedish University Hospital.

Mortality and length of stay.



EARLY DISCHARGE

Tibaldi 2009296

RCT

Hospital at Home (geriatricians, nurses, physiotherapists, social worker and counsellor).

Versus

Inpatient hospital care (general medical ward).

Elderly patients (n=101) with acute decompensation of chronic heart failure were recruited from the Emergency Department of an Italian University Teaching and Tertiary Care Hospital.

Mortality, admissions, length of stay and quality of life.



ADMISSION AVOIDANCE

Aimonino 20087

Hospital at home

Team: geriatricians, nurses,

Adults (n=104) >75 years of age, presenting with

Readmission (at 6 months), mortality at 6 month, length


Randomised controlled




RCT physiotherapists, social workers, counsellors.

Versus

Control group: routine hospital care.

acute exacerbation of COPD.

of stay, quality of life, patient satisfaction and carer stress.

trials comparing home versus hospital care treatment for acute exacerbation of COPD.

6 month follow up.

ADMISSION AVOIDANCE

Vianello 2013A304

RCT

Italy

Hospital at home:

Non-invasive ventilation (NIV) delivered at home by a portable ventilator; manually and/or mechanically assisted cough; continuous SpO2 monitoring; antibiotic therapy; pulmonology visit at home; district nurse visit at home and telephone access to pulmonologists.

Hospital group:

Received usual care, consisting of the same drugs and all other supportive measures delivered to the hospital at home group at the discretion of the ward team.

n=59

Neuromuscular disease patients with respiratory tract infection and with urgent need of hospitalisation.

Hospitalisation. ADMISSION AVOIDANCE

Hospital at Home (Primary & Secondary Care)

Nikolaus 1999216

RCT

Hospital at Home

Team: GP-led, nurses, physiotherapist and occupational therapists. Worked closely with hospital staff and primary care physician.

Versus

Control group: usual care in hospital and follow-up.

Adults (n=545) >65 years. Elderly hospitalised patients.

Mortality, readmission (at 1 year follow-up), length of stay and patient satisfaction.


12 month follow up.

EARLY DISCHARGE

Bowler Hospital at Home (in- Patients (n=25) Readmissions (at 1 In Cochrane review:




200138

RCT

patient status; home visits by nurses, GP and daily contact between these HP and hospital respiratory team)

Versus

Control: inpatient hospital care.

presenting with exacerbation of chronic obstructive pulmonary disease to emergency departments (or respiratory outpatient clinic) of hospital in Brisbane, Australia.

year follow-up). Randomised controlled trials comparing home versus hospital care treatment for acute exacerbation of COPD.

EARLY DISCHARGE

Caplan 200546

Caplan 199947

RCT

Hospital outreach team providing antibiotics, medications, blood transfusion. Team included nurse, GP, hospital physician, physiotherapists and occupational therapist.

Versus

Control group: inpatient care plus treated in accordance with standard regimens.

Adults (n=100) >65 years of age. Range of conditions including pneumonia, urinary tract infections and cellulitis, endocarditis and osteomyelitis. Recruited from admission.

Admissions, adverse events, patient satisfaction and carer satisfaction.



3 month follow up.

ADMISSION AVOIDANCE

Davies 200079

RCT

Hospital at home.

Team: nurse-led but ‘clinical responsibility for the patients remained with the hospital respiratory physician’.

Versus

Control group: hospital care as an inpatient.

Adults (n=150) with a mean age of 70 years; experiencing an acute exacerbation of COPD.

Readmissions (3 months), quality of life and mortality.


Hospital at home admission avoidance and

Randomised controlled trials comparing home versus hospital care treatment for acute exacerbation of COPD.

3 month follow up

ADMISSION AVOIDANCE

Donald 199589

RCT

Hospital at home

Team: full-time nurse, manager/coordinator, physiotherapists and occupational therapists. Overall responsibility for the

Adults (n=60) with a mean age of 82 years, who had been admitted acutely under the care of the elderly care physicians.

Readmission (6 months) and mortality.

In Cochrane review:


EARLY DISCHARGE




patient while under the care of HAH remained with the consultant, although the GP provided routine and emergency medical care.

Versus

Control group: conventional discharge.

Harris 2005138

RCT

Hospital at home

Team: nurse-led but ‘clinical responsibility was held by dedicated HAH registrar, consultant geriatrician and in some cases the GP’.

Versus

Standard hospital inpatient care.

Adults (n=285) with a mean age of 81 years presenting at ED or admitted to hospital for a broad range of diagnoses: fractures (28%); miscellaneous medical problems (18%); respiratory problems (16%); stroke and neurological diagnoses (14%); falls and injuries (11%); cardiac diagnoses (8%); and rehabilitation and other problems (5%). Location: New Zealand.

Readmission (30 days), admissions, mortality, length of stay, quality of life, carer stress, carer satisfaction and patient satisfaction.




EARLY DISCHARGE

Skwarska 2000277

RCT

Hospital at home

Team: GP and nurses. Review at weekly meetings with consultant and medical advice from on call registrar or consultant.

Versus

Control group: treated in the inpatient respiratory unit.

Adults (n=184) with an acute exacerbation of COPD.

Readmissions (at 3 months), admissions, mortality.

Included in Cochrane review: Hospital at home early discharge.


Follow up of 18 months.

EARLY DISCHARGE

Step up – Step down/Community Hospital

Applegate19 Community hospital Patients (n=155) Mortality and Not in Cochrane




9016

RCT

(geriatric assessment unit) versus usual care.

Team consisted of physicians, rehabilitation nurses, physical therapists, occupational therapist, psychologists, social workers, nutritionists and specialists in speech therapy and audiology.

Usual care: received wide range of services after discharge from the acute care hospital, include home health care and care in other rehabilitation units (that is, community services).

aged 65 years or over, risk of nursing home placement and potentially reversible functional impairment. All recruited from geriatric assessment unit.

length of stay. review.


ADMISSION AVOIDANCE

Garasen 2007110 Garasen 2008109

RCT

Community Hospital versus traditional prolonged care at a general hospital group.

Patients (n=142) aged 60 years or more admitted to the general hospital due to an acute illness or an acute exacerbation of a known chronic disease.

Mortality, readmission (26 week follow-up) and length of stay.



EARLY DISCHARGE

Herfjord 2014140

RCT

Norway

Intermediate care-

Patients transferred from hospital to a nursing home unit with increased staff and multi-disciplinary assessment for a maximum stay of 3 weeks.

Versus

Usual care in hospital.

Patients admitted acutely from home to medical or orthopaedic department, aged 70 years or older, respiratory and circulatory stable and deemed able to return home within 3 weeks.

Exclusion criteria: severe dementia, delirium, any need for surgery or intensive care treatment.

Mortality (1 year)

and length of

hospital stay.


Follow-up 1 year.

EARLY DISCHARGE

Young 2007322

Community Hospital versus general

Elderly patients (n=390) requiring

Mortality. Not in Cochrane review.




RCT

hospital. rehabilitation after hospital admission with acute illness.


EARLY DISCHARGE

Virtual Wards

Jakobsen 2015 159

RCT

Denmark

Virtual hospital - home based tele-health hospitalisation.

Participants were transported home within the first 24 hours of hospital admission. Patients were given the following equipment: touch screen with webcam, spirometer, thermometer, nebuliser, medicines and oxygen compressor.

Daily ward rounds using the touch screen at appointed hours.

Versus

Usual care- standard hospital treatment.

Patients >45 years of age, with severe or very severe COPD, who had an acute exacerbation of COPD, who were compliant, and who had an expected hospitalisation of more than 2 days.

Mortality and

quality of life.


EARLY DISCHARGE

Dhalla 201483

RCT

Virtual Ward (received usual care plus daily MDT meetings; patients were assessed by phone, at home or the clinic) versus usual care.

Adults (n=1923) at high risk of readmission (determined by length of stay, acuity of admission, comorbidities and emergency department visits in previous 6 months) being discharged from the general medicine wards of 4 participating hospitals in Toronto, Canada.

Patients: 10% heart failure, 90% other conditions (not

Mortality, readmission (at 30 days) and presentations to ED.


Outcomes closest to discharge reported that is, 30 days. Paper also reports the same outcomes at 90 days, 6 months and 1 year.

ADMISSION AVOIDANCE




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Table 3: Summary GRADE profiles for alternatives compared with hospital care

Alternatives compared to Hospital care

Outcomes No of Participants (studies) Follow up

Quality of the evidence (GRADE)

Relative effect (95% CI)

Anticipated absolute effects

Risk with Hospital care

Risk difference with Alternatives (95% CI)

Alternatives compared with Hospital at home led by primary care - early discharge

Mortality - early discharge - Hospital at home led by primary care

591 (5 studies)

⊕⊕⊝⊝ LOWa due to imprecision

RR 0.9 (0.47 to 1.71)

Moderate

69 per 1000

7 fewer per 1000 (from 37 fewer to 49 more)

Length of stay (initial inpatient days) - early discharge - Hospital at home led by primary care

222 (1 study)

⊕⊕⊕⊝ MODERATEa due to imprecision

The mean length of stay (initial inpatient days) - early discharge - hospital at home led by primary care in the intervention groups was 2.44 lower (3.34 to 1.54 lower)

Admissions - early discharge - Hospital at home led by primary care

585 (6 studies)

⊕⊕⊝⊝ LOWa,b due to risk of bias, imprecision

RR 0.92 (0.73 to 1.15)

Moderate

367 per 1000


Presentations to ED - early discharge - Hospital at home led by primary care

222 (1 study)


RR 0.44 (0.22 to 0.86)

Moderate

208 per 1000

116 fewer per 1000 (from 29 fewer to 162 fewer)

Quality of life (high score is good) - early discharge - hospital at home led by primary care (SGRQ; change score; reversed)

282 (2 studies)


The mean QOL (high score is good) - early discharge - hospital at home led by (SGRQ change score; reversed) in the intervention groups was 3.49 higher (0.38 lower to 7.36 higher)

Quality of life (higher values better QoL) - early discharge - hospital at home led by primary care (COOP chart; change score; reversed)

75 (1 study)


The mean Quality of life (higher values better QOL) - early discharge - hospital at home led by primary care (COOP chart; change score; reversed) in the intervention groups was

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0.17 standard deviations higher (0.29 lower to 0.62 higher)

Patient Satisfaction (continuous-higher values more satisfied) - early discharge - Hospital at home led by primary care

285 (2 studies)

⊕⊕⊕⊕ HIGH

The mean patient satisfaction (continuous-higher values more satisfied) - early discharge - hospital at home led by primary care in the intervention groups was 0.25 standard deviations higher (0.01 to 0.48 higher)

Patient satisfaction (dichotomous) - early discharge - Hospital at home led by Primary care

54 (1 study)

⊕⊕⊕⊝ MODERATEb due to risk of bias

RR 1.04 (0.88 to 1.24)

Moderate

889 per 1000

36 more per 1000 (from 107 fewer to 213 more)

Carer satisfaction (dichotomous) - early discharge - Hospital at home led by primary care

34 (1 study)


RR 0.97 (0.79 to 1.19)

Moderate

929 per 1000


Quality of life (high score is good) - early discharge - hospital at home led by primary care (EQ-5D; change score)

101 (1 study)


The mean Quality of life (high score is good) - early discharge - hospital at home led by primary care (eq-5d; change score) in the intervention groups was 0.04 higher (0.07 lower to 0.16 higher)

Alternatives compared with Hospital at home led by secondary care- early discharge

Mortality - early discharge - Hospital at home led by secondary care

31 (1study)

⊕⊝⊝⊝ VERY LOWa,b due to risk of bias, imprecision

RR 1.38 (0.22 to 8.59)

Moderate

111 per 1000


Readmissions-early discharge- Hospital at home led by secondary care

84 (1 study)

⊕⊝⊝⊝ VERY LOWa,b,c due to risk of bias, imprecision,

RR 0.50 (0.05 to 5.31)

Moderate

127 per 1000


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inconsistency,

Alternatives compared with Hospital at home led by primary and secondary care - early discharge

Mortality - early discharge - Hospital at home led by both primary and secondary care

895 (4 studies)

⊕⊝⊝⊝ VERY LOWa,b due to risk of bias, imprecision

RR 1.02 (0.72 to 1.44)

Moderate

140 per 1000


Readmissions (30 days) - early discharge - Hospital at home led by both primary and secondary care

285 (1 study)


RR 1.66 (0.97 to 2.83)

Moderate

127 per 1000


Admissions - early discharge - Hospital at home led by both primary and secondary care

835 (5 studies)


RR 0.94 (0.74 to 1.2)

Moderate

200 per 1000


Length of stay (days in treatment) - early discharge - Hospital at home led by primary and secondary care

285 (1 study)


The mean length of stay (days in treatment) - early discharge - hospital at home led by primary and secondary care in the intervention groups was 3.1 higher (1.81 to 4.39 higher)

Carer satisfaction (dichotomous) - early discharge - Hospital at home led by both primary and secondary care

127 (1 study)


RR 1.61 (1.14 to 2.28)

Moderate

414 per 1000

253 more per 1000 (from 58 more to 530 more)

Patient Satisfaction (continuous-higher values more satisfied) - early discharge - Hospital at home led by primary and secondary care

281 (1 study)


The mean patient satisfaction (continuous-higher values more satisfied) - early discharge - hospital at home led by primary and secondary care in the intervention groups was 0.25 standard deviations higher (0.01 to 0.48 higher)

Quality of life (high score is good) - early discharge - hospital at home led by primary and secondary care

241 (1 study)

⊕⊕⊕⊕ HIGH

The mean Quality of life (high score is good) - early discharge - hospital at home led by primary and

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(final score; SF-36; physical) secondary care (final score; sf-36; physical) in the intervention groups was 0.4 higher (2.2 lower to 3 higher)

Patient satisfaction (dichotomous) - early discharge - Hospital at home led by both primary and secondary care

232 (1 study)


RR 1.15 (1 to 1.32)

Moderate

725 per 1000

109 more per 1000 (from 0 more to 232 more)

Quality of life (high score is good) - early discharge - hospital at home led by primary and secondary care (final score; SF-36; mental)

241 (1 study)

⊕⊕⊕⊕ HIGH

The mean Quality of life (high score is good) - early discharge - hospital at home led by primary and secondary care (final score; sf-36; mental) in the intervention groups was 1.3 higher (1.55 lower to 4.15 higher)

Alternatives compared with step-up/down care- early discharge

Mortality - early discharge - Step up/down care 1008 (3 studies)


RR 0.88 (0.71 to 1.1)

Moderate

215 per 1000

26 fewer per 1000 (from 62 more to 22 more)

Length of stay (initial inpatient days) - early discharge - Step up/down care

518 (2 studies)

⊕⊝⊝⊝ VERY LOWa,b,c due to risk of bias, inconsistency, imprecision

The mean length of stay (initial inpatient days) - early discharge - step up/down care in the intervention groups was 3.59 higher (1.23 to 5.95 higher)

Readmissions - early discharge - Step up/down care 142 (1 study)


RR 0.54 (0.31 to 0.96)

Moderate

357 per 1000


Alternatives compared with virtual wards- early discharge

Mortality- early discharge- virtual wards 57 ⊕⊝⊝⊝ RR 0.72 Moderate

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(1 study) VERY LOWa,b due to risk of bias, imprecision

(0.18 to 2.95)

143 per 1000

40 fewer per 1000 (from 117 more to 279 more)

Quality of life -early discharge- virtual wards (EQ-5D summary index; change score)

57 (1 study)


The mean Quality of life -early discharge- virtual wards (eq-5d summary index; change score) in the intervention groups was 0.00 higher (0.15 lower to 0.15 higher)

Alternatives compared with hospital at home led by primary care- admission avoidance

Mortality - Admission avoidance - Hospital at home led by primary care

285 (2 studies)


RR 0.82 (0.53 to 1.29)

Moderate

309 per 1000


Admissions(>30 days) - Admission avoidance - Hospital at home led by primary care

285 (2 studies)


RR 1.29 (0.73 to 2.29)

Moderate

100 per 1000


Adverse events - Admission avoidance - Hospital at home led by primary care

49 (1 study)


RR 1.3 (0.62 to 2.73)

Moderate

320 per 1000


Days to discharge (hazard ratio) - Admission avoidance - Hospital at Home Primary Care (Hazard Ratio)

194 (1 study)


HR 0.95 (0.71 to 1.27)

Moderate

0 per 1000

-

Patient satisfaction (dichotomous) - Admission avoidance - Hospital at home led by Primary care

179 (1 study)

⊕⊕⊕⊕ HIGH

RR 0.97 (0.92 to 1.02)

Moderate

989 per 1000


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Readmissions(<30 days) - Admission avoidance - Hospital at home led by primary care

307 (2 studies)

⊕⊕⊕⊕ HIGH

RR 4.68 (1.53 to 14.31)

Moderate

31per 1000

31per 1000

Quality of life (high score is good) - Admission avoidance - hospital at home led by primary care (final score; SF-12; mental)

49 (1 study)


The mean Quality of life (high score is good) - admission avoidance - hospital at home led by primary care (final score; sf-12; mental) in the intervention groups was 0.6 lower (5.46 lower to 4.26 higher)

Quality of life (high score is good) - Admission avoidance - hospital at home led by primary care (final score; SF-12; physical)

49 (1 study)


The mean Quality of life (high score is good) - admission avoidance - hospital at home led by primary care (final score; sf-12; physical) in the intervention groups was 3.6 lower (8.78 lower to 1.58 higher)

Alternatives compared with hospital at home led by secondary care- admission avoidance

Mortality - Admission avoidance - Hospital at home led by secondary care

329 (4 studies)


RR 0.8 (0.47 to 1.35)

Moderate

150 per 1000


Admissions(>30 days) - Admission avoidance - Hospital at home led by secondary care

252 (3 studies)


RR 0.56 (0.42 to 0.75)

Moderate

500 per 1000


Length of stay (days in treatment) - Admission avoidance - Hospital at home led by secondary care

172 (2 studies)

⊕⊕⊝⊝ LOWb,d due to risk of bias, inconsistency

The mean length of stay (days in treatment) - admission avoidance - hospital at home led by secondary care in the intervention groups was 4.69 higher (2.86 to 6.52 higher)

Quality of life high score is good) - Admission 71 ⊕⊕⊝⊝

The mean Quality of life (high score is good) -

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avoidance - hospital at home led by secondary care (change score; SF-36; mental)

(1 study) LOWa,b due to risk of bias, imprecision

admission avoidance - hospital at home led by secondary care (change score; sf-36; mental) in the intervention groups was 1.2 higher (1.46 lower to 3.86 higher)

Patient satisfaction (dichotomous) - Admission avoidance - Hospital at home led by secondary care

104 (1 study)

⊕⊕⊕⊕ HIGH

RR 1.07 (0.95 to 1.2)

Moderate

885 per 1000


Quality of life (high score is good) - Admission avoidance- hospital at home led by secondary care (NHP, change score; reversed)

205 (2 studies)

⊕⊕⊕⊝ MODERATEe due to inconsistency

The mean Quality of life (high score is good) - admission avoidance - hospital at home led by secondary care (nhp, change score; reversed) in the intervention groups was 1.13 higher (0.29 to 1.97 higher)

Quality of life (high score is good) - Admission avoidance- hospital at home led by secondary care (change score; SF-36; physical)

71 (1 study)


The mean Quality of life (high score is good) - admission avoidance - hospital at home led by secondary care (change score; sf-36; physical) in the intervention groups was 1.4 higher (2.38 lower to 5.18 higher)

Alternatives compared with hospital at home led by primary and secondary care- admission avoidance

Adverse events - Admission avoidance - Hospital at home led by both primary and secondary care

100 (1 study)


RR 0.72 (0.27 to 1.93)

Moderate

163 per 1000


Admissions(>30 days) - Admission avoidance - Hospital at home led by both primary and secondary care

250 (2 studies)


RR 1.14 (0.74 to 1.74)

Moderate

221 per 1000


Mortality - Admission avoidance - Hospital at home led by both primary and secondary care

150 (1 study)


RR 1.12 (0.36 to 3.47)

Moderate

80 per 1000


Patient Satisfaction (continuous-higher score is good) - Admission avoidance - Hospital at home led by

60 (1 study)

⊕⊕⊝⊝ LOWa

The mean patient satisfaction (continuous-higher score is good) - admission avoidance - hospital at

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primary and secondary care (reversed scale) due to imprecision

home led by primary and secondary care (reversed scale) in the intervention groups was 1.98 standard deviations higher (1.33 to 2.64 higher)

Carer satisfaction (continuous) - Admission avoidance - Hospital at home led by primary and secondary care

41 (1 study)

⊕⊕⊕⊕ HIGH

The mean carer satisfaction (continuous) - admission avoidance - hospital at home led by primary and secondary care in the intervention groups was 1.55 standard deviations higher (0.8 to 2.29 higher)

Quality of life (high score is good) - Admission avoidance - hospital at home led by primary and secondary care (SGRQ; change score; reversed)

50 (1 study)


The mean Quality of life l (high score is good) - admission avoidance - hospital at home led by primary and secondary care (sgrq; change score; reversed) in the intervention groups was 2.83 lower (11.75 lower to 6.09 higher)

Alternatives compared with step-up/down care- admission avoidance

Length of stay (initial inpatient days) - Admission avoidance - Step up/down care

155 (1 study)


The mean length of stay (initial inpatient days) - admission avoidance - step up/down care in the intervention groups was 4.1 lower (8.58 lower to 0.38 higher)

Mortality - Admission avoidance - Step up/down care 155 (1 study)


RR 0.49 (0.22 to 1.09)

Moderate

208 per 1000


Alternatives compared with virtual wards- admission avoidance

Mortality - Admission avoidance - Virtual wards 1913 (1 study)


RR 0.85 (0.56 to 1.28)

Moderate

49 per 1000


Readmissions (30 days) - Admission avoidance - Virtual wards

1919 (1 study)

⊕⊕⊕⊕ HIGH

RR 0.89 (0.74 to 1.06)

Moderate

213 per 1000


Presentations to ED - Admission avoidance - Virtual wards

1920 (1 study)

⊕⊕⊕⊕ HIGH

RR 0.95 (0.82 to

Moderate

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(a) Downgraded by 1 increment if the confidence interval crossed 1 MID point, and downgraded by 2 increments if the confidence interval crossed 2 MID points. (b) Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias. (c) Downgraded by 1 or 2 increments because heterogeneity, I2=92%, unexplained by sub-group analysis. (d) Downgraded by 1 or 2 increments because heterogeneity, I2=88%, unexplained by sub-group analysis. (e) Downgraded by 1 or 2 increments because heterogeneity, I2=50%, unexplained by sub-group analysis.



Narrative findings

Length of hospital stay

Cotton 200067

Mean length of initial admission (range) for the early discharge group 3.2 (1-16) and for conventional management 6.1 (1-13).

Richards 2005242

The median number of days to discharge in the home group was 4 (range: 1-14), compared with 2 (range, 0-10) in the hospital group (p=0.004).

Wilson 1999312

Analyses by intention to treat showed significantly shorter stays in care for the hospital at home group than for the hospital group (median initial stay, 8 days versus 14.5 days, p=0.026); median total days of care in 3 months, 9 days versus 16 days, p=0.031.

Donald 199589

At 6 months the hospital at home total days in hospital (after study entry) of 22.5 (IQR 5-30) and the control group a mean number of days of 20.2 (IQR 8-27).

Applegate 199016

The mean length of stay in the geriatric assessment unit was 23.6 (+/-13.2) days. For the high risk stratum, the average stay was 28.6 (+/-14.4days) and for the lower risk stratum it was 21.1 (+/-11.9) days.

Zimmer 1985325

Mean length of hospital stay during first 6 months for intervention (n=81) was 12.6 days and for control was 14.3 days.

Emergency department visits Aiken 20066

In the 6 months prior to the onset of PhoenixCare intervention, PhoenixCare participants averaged 0.12 emergency department visits per month (SD=0.18). Control participants averaged 0.11 emergency department visits per month (SD=0.02). This level of utilisation remained essentially unchanged during the intervention, with averages of 0.11 (SD=0.34) and 0.10 (SD=0.31) visits per month for Phoenix Care and control participants, respectively.

Zimmer 1985325

Mean ED visits per patient per month for days at risk in the first 6 months of study; intervention (n=81) 0.26 and control (n=75) 0.05.

Quality of Life

Applegate 199016



The group assigned to the geriatric assessment unit had significantly more improvement (p<0.05) than the control group in regard to 3 basic self-care activities (bathing, dressing and the ability to transfer) during the 6 months after randomisation.

Patient satisfaction

Richards 2005242

Patient satisfaction with medical and nursing care was high in both groups, but significantly higher in the home care group (p=0.001). In the home care group, all patients reported that they were ‘very happy’ with their care. In the hospital care group, 60% were ‘very happy’, 32% ‘quite happy’ and 8% ‘neither happy nor unhappy’.

Wilson 2002314

Patient satisfaction was greater with Hospital at Home than with hospital. Reasons included a more personal style of care and a feeling that staying at home was therapeutic. Carers did not feel that Hospital at Home imposed an extra workload.

Skwarska277

Replies to the questionnaires on satisfaction with the service were received from 69% of the patients treated at home, 95% of whom said they were ‘completely satisfied’ with the services and 90% felt they had been cared for just as well or better at home than they would have been in hospital.

Young 2007322

The reported patient satisfaction was similar for both groups. At 1 week after hospital discharge, the community hospital group showed greater satisfaction with the statement ‘I am happy with the amount of recovery I have made’ (odds ratio=2.12, 95% CI=1.30-3.46; p=0.004).

Zimmer 1985325

Mean unadjusted patient satisfaction scores at 6 months for the community palliative group was 95.0 (n=31; p=not statically significant) and for the control group 89.3 (n=22; p=not statically significant).

Carer satisfaction

Donald 199589

There were 13 HAH carers and 7 control group carers, all of whom were interviewed at each assessment. A large majority of carers were happy with the timing of discharge. Questions ratings carer’s opinions of how good they were at the caring role, and how well they were coping, were answered similarly with 2 HAH carers and 1 control group carer admitting difficulties in coping. No clear differences between the groups emerged, but the numbers were small.



Carer stress

Tibaldi 2009296

The level of stress of the caregiver was high on admission in both groups but more severe in caregivers of Geriatric Home Hospital Service (relative stress scale score, 25.4 [16.6] versus 17.1 [10.8] in the general medical ward group; p=0.003).



12.4 Economic evidence

Twelve economic evaluations, published in 13 papers, relating to hospital-at-home, virtual wards and step-up/step down community care have been included in this review.7,23,102,118,202,204,229,235,242,288,292,296,304 One study204 was relevant to all 3 of these strata.

These are summarised in the economic evidence profile tables (Table 4, to Table 10) and the economic evidence tables in Appendix E.

One study239 of hospital-at-home was excluded due to very serious limitations and three more17,165,225 were selectively excluded because there was better quality evidence available. One paper relating to step-up/step-down interventions was identified but was excluded due to the availability of more applicable evidence.221 Another paper relating to virtual wards was identified but excluded due to serious limitations.186 All of these are listed in Appendix H, with reasons for exclusion given.

The economic article selection protocol and flow chart for the whole guideline can found in the guideline’s Appendix 41A and Appendix 41B.

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Table 4: Economic evidence summary - Hospital at home versus inpatient care

Study Country Subgroup Study design Population Incremental cost per patient

Main incremental effect per patient

Cost effectiveness

Admission avoidance

Aimonino Ricauda 20087

Italy Hospital-led RCT COPD Saves £202 -6% mortality HaH dominates

Mendoza 2009202

Spain Hospital-led RCT Heart Failure Saves £2800 -3.4% mortality HaH dominates

Richards 2005242 New Zealand Primary care-led

RCT Community acquired pneumonia

Saves £171 4.3% avoidable adverse events

Inpatient care costs £3,976 per AE avoided

Tibaldi 2009296 Italy Hospital RCT Heart Failure Saves £217 No difference in mortality

HaH dominates

Thornton 2005292 &Elliott 2005102

UK Hospital-led Retrospective cohort study

Cystic Fibrosis Saves £9,081 -16.2% patients with </= 0% decline in respiratory function

Inpatient care costs £46,098 per extra patient with no decline

Vianello 2013304 Italy Both hospital and primary care

RCT Neuromuscular disease patients with Respiratory tract infection

Saves £7,395 -3.3% mortality HaH dominates

Early discharge

Goossens 2013118

Netherlands Primary care-led

RCT COPD Saves £131 -0.005 QALYs Inpatient care cost £24,000 per QALY

Note: All studies were rated as partially applicable with potentially serious limitations – QALYs were rarely estimated; not all costs were included; only 2 studies were from a UK NHS perspective; based on individual studies rather than a systematic review of the evidence. AE: adverse events; COPD=chronic obstructive pulmonary disease; HaH=Hospital-at- home; RCT=randomised controlled trial.

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Study Country Subgroup Study design Population Incremental cost per patient

Main incremental effect per patient

Cost effectiveness

Both admission avoidance and early discharge

Bakerly 200923 UK Hospital-led Matched case-control

COPD Saves £600 N/A HaH cost-saving

Patel 2008229 Sweden Hospital-led RCT Heart failure Saves £1960 +0.01 QALYs HaH dominates

Puig-Junov 2007235

Spain Primary care-led

RCT COPD Saves £560 -2.8% mortality (Hernandez 2003141)

HaH dominates

Teuffel 2011288 Canada Hospital-led Decision tree Cancer with low risk febrile neutropenia

Saves £4,000-£5,500

+0.03-0.1 QAFNEs HaH dominates

Note: All studies were rated as partially applicable with potentially serious limitations – QALYs were rarely estimated; not all costs were included; only 2 studies were from a UK NHS perspective; based on individual studies rather than a systematic review of the evidence.

COPD=chronic obstructive pulmonary disease; HaH=Hospital-at- home; N/A: not applicable (for comparative costing studies); QALY=quality-adjusted life-year; QAFNE=quality-adjusted febrile neutropaenia episode; RCT=randomised controlled trial.

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Table 5: Economic evidence profile: Hospital at home versus inpatient hospital care – Admission avoidance

Study Applicability Limitations Other comments Incremental cost

Incremental effects

Cost effectiveness Uncertainty


Partially applicable(a)

Potentially serious limitations(b)

RCT. Elderly patients aged > 75 years, with exacerbation of COPD who were assessed in the ED for at least 12 to 24 hours and with stable clinical condition.

Admission to a physician-led, substitutive clinical unit model at a geriatric home under the care of a team of geriatricians, nurses, physiotherapists, social workers and counsellors (hospital-at-home). Compared to admission to hospital ward.

Saves £202 -6% mortality HaH dominates

No sensitivity analysis reported

Mendoza 2009202

Partially applicable(c)

Potentially serious limitations(d)

RCT. Elderly patients (>65 years)

presenting to the ED with decompensated heart failure.

HaH vs inpatient hospital care.

Saves £2800 -3.4% mortality

HaH dominates

No sensitivity analysis reported.

Richards 2005242

Partially applicable(e)

Potentially serious limitations(f)

RCT. Patients presenting to the ED with a

clinical diagnosis of community-acquired pneumonia that is mild to moderately severe and who are low risk (CURB-65 score of 0-2).

Treatment at home delivered by primary care teams under the Extended Care @Home program which provides extended medical and nursing care to patients in their home. Compared to in-hospital antibiotic treatment

Saves £171 4.3% avoidable adverse events

Inpatient care costs £3,976 per AE avoided


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Study Applicability Limitations Other comments Incremental cost

Incremental effects


Tibaldi 2009296

Partially applicable(g)

Potentially serious limitations(h)

RCT. Patients, 75 years or older, with a

pre-existing diagnosis of CHF and persistent functional impairment indicative of New York Heart Association class III or IV.

Hospital-led geriatric hospital-at-home service provided by a multidisciplinary team compared to routine hospital care in a general medical ward.

Saves £217 No difference in mortality

HaH dominates


Thornton 2005292

&Elliott 2005102

Partially applicable(i)

Potentially serious limitations(j)

Retrospective cohort study. Adults with

confirmed cystic fibrosis (CF) who experienced at least one respiratory exacerbation during the study period.

Intervention: Home treatment with IV antibiotics, where the patient received >60% of the treatment courses at home.

Comparator: Hospital treatment with intravenous (IV) antibiotics, where the patient received >60% of the treatment courses at hospital.

Saves £9,081 -16.2% patients with </= 0% decline in respiratory function

Inpatient care costs £46,098 per extra patient with no decline

No sensitivity analysis reported. Bootstrapping of cost data was used to calculate CIs

Vianello 2013304

Partially applicable(k)

Potentially serious limitations(l)

RCT. Adult neuromuscular patients with

respiratory tract infection requiring hospital admission

Intervention: Treatment at home under the care of a Hospital-at-home service. The service was delivered primarily by a district nurse with follow-up from a pulmonologist and respiratory therapist.

Comparator: Admission to hospital for inpatient treatment of respiratory tract infection.

Saves £7,395 -3.3% mortality

HaH dominates


COPD=chronic obstructive pulmonary disease; HaH=Hospital-at- home; RCT=randomised controlled trial.

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(a) QALYs are not used as an outcome measure. Some uncertainty regarding the applicability of Italian resource use (2005) and unit costs (2005) to the NHS context. (b) Within-trial analysis; so does not reflect all the evidence available for this comparison. Local unit costs from hospital records were used; so may not reflect national unit costs. Uncertainty

was not appropriately addressed and no sensitivity analysis undertaken. (c) QALYs are not used as outcome measure. Spanish resource use data (2006-2007) and unit costs (2008), so some uncertainty about the applicability of resource use and costs to current

NHS context. (d) RCT-based analysis, so from one study by definition therefore not reflecting all evidence in area. Some local costs used; so there is uncertainty as to whether these will reflect national

costs. Some uncertainty about whether time horizon is sufficient to capture all benefits and costs. (e) There is uncertainty about the applicability of resource use (2002-2003) and unit costs (2003) from New Zealand to the NHS context. QALYs were not used as an outcome measure. (f) Within-trial analysis so does not reflect all the evidence available for this comparison. The short time horizon (6 weeks) may not reflect all potential differences in costs and outcomes. Unit

costs from EC@H service records were used to calculate the costs for patients in the home treatment group. It is not clear whether these costs are national level. Univariate analysis was used in the comparison and no sensitivity analysis was undertaken.

(g) Cost-consequences analysis, so QALYs are not used as outcome. Some uncertainty about the applicability of resource use and unit costs from Italy in 2005 to the current NHS context. RCT-based analysis so from one study by definition therefore not reflecting all evidence in area.

(h) There is some uncertainty about whether time horizon is sufficient to reflect all the possible downstream differences in costs and outcomes. The sources of unit costs are not clearly described, so not clear whether they are local or national unit costs. No sensitivity analysis is reported.

(i) QALYs are not used as outcome. (j) Some uncertainty about the applicability of resource use and unit costs from 2002 to the current NHS context. Retrospective observational study, so by definition not reflecting all

evidence in this area. Univariate analysis was used, so results subject to confounding. Some uncertainty about whether time horizon is sufficient to reflect all differences in costs and outcomes. Both local and National unit costs used, so some uncertainty regarding whether the local costs reflect national averages. Limited sensitivity analysis presented.

(k) Cost-consequences analysis, so QALYs are not used as outcome. Some uncertainty about the applicability of resource use and unit costs from Italy in 2010 to the current NHS context. (l) RCT-based analysis so from one study by definition therefore not reflecting all evidence in area. It is not clear whether the cost of hospitalisation is included for those patients in the

hospital at home arm who failed treatment and required hospitalisation. Unit costs from both local and national sources so may not be completely reflective of national unit costs. No sensitivity analysis is reported.

Table 6: Economic evidence profile: Hospital at home versus inpatient hospital care – Early discharge

Study Applicability Limitations Other comments Incremental cost Incremental effects


Goossens 2013118



RCT. Patients (40 years or older)

admitted to one of the participating hospitals for a COPD exacerbation.

Early supported discharge scheme (hospital-at-home) after an initial 3 days under usual hospital treatment involving treatment and supervision at home for the remaining 4 days by a community nurse who is generically trained

Saves £131 -0.005 QALYs

Inpatient care cost £24,000 per QALY

Probability Intervention cost saving:

61.2%

Probability Intervention cost-effective at

20K/30K threshold): 58%/55%

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(not specialist).

COPD=chronic obstructive pulmonary disease; HaH=Hospital-at- home; QALY=quality-adjusted life-year; RCT=randomised controlled trial. (a) Some uncertainty regarding the applicability of resource use (2007-2011) and unit costs (2009) from the Netherlands. (b) RCT-based analysis, so from one study by definition therefore not reflecting all evidence in area that compares early supported discharge versus inpatient admission. Micro-costing study

was used to calculate the cost of inpatient bed day cost in the base case analysis, which does not reflect the national unit cost for inpatient hospital day. Some uncertainty about whether time horizon of 3 months is sufficient to capture all benefits and costs.

Table 7: Economic evidence profile: Hospital at home versus inpatient hospital care – Both admission avoidance and early discharge



Bakerly 200923



Matched case-control study. Patients admitted to a university hospital with acute exacerbation of COPD.

Care delivered by an acute COPD assessment service, which provided an integrated care model. Compared to usual inpatient care.

Saves £600 N/A HaH cost-saving No sensitivity analysis reported

Patel 2008229

Partially applicable(c)

Potentially serious limitations(d)

RCT

Patients seeking care for deterioration of chronic heart failure identified within 24-48 hours after admission from three medical facilities: ED, Heart failure outpatient clinic and a medical ward.

Home care under the direction of a

Saves £1960 +0.01 QALYs HaH dominates Various sensitivity analyses were conducted but HAH continued to dominate

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specialist nurse (HC) versus hospital inpatient care.

Puig-Junov 2007235

Partially applicable(e)

Potentially serious limitations(f)

RCT. Patients presenting to ED with

acute exacerbation of COPD.

Nurse-led hospital-at-home involving up to 5 visits from specialist respiratory nurse and phone consultation whenever needed. Compared to inpatient hospital care.

Saves £560 -2.8% mortality (Hernandez 2003141)

HaH dominates No sensitivity analysis reported

Teuffel 2011288

Partially applicable(g)

Potentially serious limitations(h)

Decision tree. Adult cancer

patients low risk of febrile neutropenia receiving antibiotic treatment.

Intervention 1. Inpatient IV antibiotics

Intervention 2. Inpatient IV antibiotics and then early discharge with oral antibiotics

Intervention 3. Home IV antibiotics

Intervention 4. Home oral antibiotics

Saves £4,000-£5,500

(2/3/4 vs 1)

+0.03-0.1 QAFNEs

(2/3/4 vs 1)

HaH dominates

(2/3/4 vs 1)

PSA was used. The results were sensitive to variations in the costs of in-patient stay, outpatient visits, and home nurse visits. The duration of treatment and some utility assumptions were also key inputs. In some scenarios, home intravenous treatment was the preferred strategy, but the in-patient treatments were never cost-effective.

COPD=chronic obstructive pulmonary disease; HaH=Hospital-at- home; IV: intravenous; N/A: not applicable (for comparative costing studies); QALY=quality-adjusted life-year; QAFNE=quality-adjusted febrile neutropenia episode; RCT=randomised controlled trial.

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(a) The model evaluated in the study is an integrated care model, with hospital at home representing one component of the model. The study compares costs only and no health outcomes are considered. No sensitivity analysis is reported.

(b) Some uncertainty exists regarding the applicability of resource use and costs from 2007 to the current NHS context. QALYs were not used as an outcome measure as the study compares costs only. Observational, matched case control study with no adjustment for possible confounders other than the matching variables. So, so does not reflect all the evidence available for this comparison. One year follow-up; so may not capture the long-term consequences of the intervention.

(c) Some uncertainty about the applicability of resource use and costs (2004-2006) from Sweden. QALYs are calculated using the VAS values. (d) RCT-based analysis so from one study by definition therefore not reflecting all evidence in area. Local costs are used; some uncertainty as to whether these reflect national costs. Some

uncertainty regarding whether time horizon is sufficient (12 months follow-up). Limited number of deterministic sensitivity analyses presented. (e) Uncertainty regarding the applicability of resource use (1999-2000) and unit costs (2000) from Spain to the UK NHS context. Comparative cost analysis, assuming equivalent outcomes, so

QALYs are not used as an outcome measure. (f) Short time horizon (8 weeks) which might not capture all the differences in costs. Within-trial comparative costing analysis so does not reflect all the evidence in this area. The authors

assumed equivalent health outcomes despite a previous publication from the same trial reporting favourable outcomes for hospital-at-home. Uncertainty was not adequately addressed and no sensitivity analysis undertaken.

(g) Some uncertainty regarding the applicability of resource use and unit costs from Canada (2009). The outcome used is not QALYs, but rather a quality adjusted FN episode. (h) The short time horizon used (30 days) might not reflect all differences between strategies in terms of costs and outcomes. Some local costs were used to calculate the costs of hospital

fees/charges and home care nurse visits. It was not reported how the baseline risk studies were identified. The cost-effectiveness threshold used in the PSA was arbitrary and may not have a meaningful interpretation.

Table 8: Economic evidence profile: Step up/Step-down care versus inpatient hospital care



Monitor 2015204



Hospital simulation model

Short-term treatment to patients who are not suffering a hyper-acute episode in a community hospital setting. Patients referred by GP or ambulance, receiving treatment within two hours from a multidisciplinary team led by a consultant, seven days a week. Compared to usual hospital care.

Total cost over five years: £1m

Total cost in fifth year (per patient): -£115

N/A N/A Estimated that a similar scheme would need to cost around £550 to £600 per patient intervention to be cost saving compared to treating patients in the acute setting.

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O’Reilly 2008220

partially applicable(c)

Minor limitations(d)

RCT (same paper) – 6 months

Population: Older people needing rehabilitation after an acute illness for which they required admission to hospital

Two comparators:

1. Multidisciplinary care in a district general hospital at the department for care of elderly people

2. Prompt transfer to the locality based community hospital

2 versus 1

Total cost (mean per patient):

£720

2 versus 1

QALYs gained (mean per patient):

0.048

2 versus 1

ICER= £16,324 per QALY gained

Costs of initial hospital admission, subsequent readmission and institutional care costs were explored in sensitivity analyses which gave similar results to the base case

analysis. (e)

(a) No health outcomes. (b) Not enough detail around methodology and modelled cohort. Costs not explicitly reported as per patient value. Full breakdown of cost inputs and outputs not reported. (c) Unit costs from 2001-2002. (d) Within-trial analysis so does not reflect all the evidence available for this comparison between care at a community hospital and at a district general hospital setting. The short time

horizon (6 months) may not reflect all potential differences in costs and outcomes. An assumption was also made about the persistence of effect up to 1 year, which was not supported by evidence. Both local and national unit costs were used for the analysis. It is not clear whether the local unit costs used for some of the community care resources would be representative of national unit costs. Additionally, only a limited number of assumptions was tested in sensitivity analysis.

(e) A threshold analysis showed that when the per diem cost of the community hospital is reduced by over 30%, the mean cost per patient treated at a community hospital becomes lower than at a general hospital.

Table 9: Economic evidence profile: Virtual wards care versus inpatient care



Monitor 2015204




24-hour remote triaging, advice and treatment to patients through video link. Aim to prevent unwell patients from attending hospital.



N/A N/A Estimated that a similar scheme would need to cost around £4,000 to £4,300 per patient intervention to be cost saving compared to treating patients in the acute setting.

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Scheme provided by senior nurses to primarily frail elderly living in nursing homes. Compared to usual hospital care.

(a) No health outcomes. (b) Not enough detail around methodology and modelled cohort. Costs not explicitly reported as per patient value. Full breakdown of cost inputs and outputs not reported.

Table 10: Economic evidence profile: Rapid response scheme versus usual inpatient care



Monitor 2015204




Intervention was rapid response plus early supported discharge Rapid response and early supported discharge scheme. Scheme ran by a single consultant-led multidisciplinary team, seven days a week within patients own home. Scheme targets patients identified in acute inpatient wards, often recovering from an operation. Compared with usual hospital care.



N/A N/A Estimated that a similar scheme would need to cost around £350 per patient intervention to be cost saving compared to treating patients in the acute setting.

(a) No health outcomes. (b) Not enough detail around methodology and modelled cohort. Full breakdown of cost inputs and outputs not reported.



12.5 Evidence statements

12.5.1 Clinical

Strata – Early discharge

Six studies comprising 591 people evaluated the role of hospital at home led by primary care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that hospital at home led by primary care may provide a benefit in reduced admissions (6 studies, low quality), presentations to ED (1 study, moderate quality), hospital length of stay (1 study, moderate quality), quality of life (various scores reported total of 5 studies, low to moderate quality) and patient satisfaction (continuous outcome: 2 studies, high quality and dichotomous; 1 study, moderate quality). The evidence suggested that there was no effect on mortality (5 studies, low quality) and there was a possible reduction in carer satisfaction (1 study, moderate quality) in hospital at home led by primary care compared to hospital care.

One study comprising 197 people evaluated the role of hospital at home led by secondary care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that hospital at home led by secondary care may provide a benefit in reduced re-admissions (1 study, very low quality). There was a possible increase in mortality (1 study, very low quality) in hospital at home led by secondary care compared to hospital care.

Five studies comprising 895 people evaluated the role of hospital at home led by both primary and secondary care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence showed that hospital at home led by primary and secondary care provided a benefit in reduced admissions (5 studies, moderate quality), and carer satisfaction (1 study, moderate quality). The evidence suggested that there was no effect on mortality (4 studies, very low quality). There was an increase in re-admissions (1 study, moderate quality) and length of stay (1 study, moderate quality) in hospital at home led by both primary and secondary care compared to hospital care. Evidence on quality of life showed no difference in 1 study and an improvement in another study (both moderate quality). Similarly, patient satisfaction in 1 study showed no difference the other showed an improvement (both high quality).

Three studies comprising 1008 people evaluated the role of step-up/down care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that step-up/down care may provide a benefit in reduced mortality (3 studies, low quality) and readmissions compared to hospital care. There was a suggested increase in length of stay (2 studies, very low quality) in step-up/down care compared to hospital care.

One study comprising 57 people evaluated the role of virtual wards in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that virtual wards may provide a benefit in reduced mortality (1 study, very low quality). The evidence suggested that there was no effect on quality of life (1 study, moderate quality) in virtual wards compared to hospital care.

Strata – Admission avoidance

Four studies comprising 571 people evaluated the role of hospital at home led by primary care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that hospital at home led by primary care may provide a benefit in reduced mortality (2 studies, moderate quality) and quality of life on SF-12 physical scores ((1 study, moderate quality). The evidence suggested that there was no effect on days to discharge (1 study, low quality). There was an increase in readmissions under 30 days (2 studies, high quality), adverse events (1 study, low



quality) and reduced patient satisfaction (1 study, high quality) in hospital at home led by primary care compared to hospital care. No difference was identified for admissions over 30 days (2 studies, low quality) and quality of life on SF-12 mental scores (1 study, low quality).

Four studies comprising 329 people evaluated the role of hospital at home led by secondary care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that hospital at home led by secondary care may provide a benefit in reduced mortality (4 studies, low quality), reduced admissions after 30 days (3 studies, low quality), improved patient satisfaction (1 study, high quality) and quality of life (3 different scores reported, low to moderate quality). The evidence suggested that there was increased length of stay (2 studies, low quality) in hospital at home led by secondary care compared to hospital care.

Two studies comprising 252 people evaluated the role of hospital at home led by both primary and secondary care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that hospital at home led by primary and secondary care may provide a benefit in improved patient satisfaction (1 study, low quality), carer satisfaction (1 study, high quality) and reduced adverse events (1 study, low quality). There was a possible increase in mortality (1 study, low quality), admissions (2 studies, low quality) and reduced quality of life (1 study, moderate quality) in hospital at home led by both primary and secondary care compared to hospital care.

One study comprising 155 people evaluated the role of step-up/down care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested step-up/down care may provide a benefit in reduced mortality (1 study, moderate quality) and length of stay (1 study, low quality) compared to hospital care.

One study comprising 1920 people evaluated the role of virtual wards in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that virtual wards provide a benefit in reduced mortality (1 study, low quality), reduced re-admissions (1 study, high quality) and presentations to ED (1 study, high quality) compared to hospital care.

12.5.2 Economic

Four cost-effectiveness analyses and one cost-utility analysis found that hospital at home led by secondary care dominated inpatient care. One cost analysis found it to be cost saving (cost difference: £600 per patient) and one cost effectiveness analysis showed that inpatient care was more costly and more effective (£46,000 per extra patient with no decline in respiratory function). These studies were assessed as partially applicable with potentially serious limitations.

One cost-utility analysis found that inpatient care was not cost effective at a threshold of £20,000 per QALY compared with hospital at home led by primary care but it was cost-effective at a threshold of £30,000 per QALY gained (ICER:£24,000 per QALY gained). One cost-effectiveness analysis found that inpatient care was dominated. One cost-effectiveness analysis found that inpatient care was more effective but more costly (£4,000 per adverse event avoided). These studies were assessed as partially applicable with potentially serious limitations.

One cost-effectiveness analysis found that hospital at home led by both primary and secondary care dominated inpatient care. This study was assessed as partially applicable with potentially serious limitations.

One cost-utility analysis found that step up/step down was cost effective compared with inpatient care (ICER: £16,300 per QALY gained). One cost comparison study found that it was cost saving (cost difference: £115 per patient). These studies were assessed as partially applicable with potentially serious limitations.



One cost comparison study found that virtual wards are cost saving (cost difference: £404 per patient). This study was assessed as partially applicable with potentially serious limitations.

One cost comparison study found that rapid response and early supported discharge was cost saving (cost difference: £116 per patient). This study was assessed as partially applicable with potentially serious limitations.



12.6 Recommendations and link to evidence

Recommendations 6. Provide multidisciplinary intermediate care as an alternative to hospital care to prevent admission and promote earlier discharge. Ensure that the benefits and risks of the various types of intermediate care are discussed with the person and their family or carera.

Research recommendations -

Relative values of different outcomes

Quality of life, mortality, avoidable adverse events, patient and/or carer satisfaction and number of admissions to hospital were considered by the committee to be critical outcomes.

Number of GP presentations, readmission, length of hospital stay and number of presentations to the Emergency Department were considered by the committee to be important outcomes.

Trade-off between benefits and harms

This review examined evidence for the following interventions:

• Hospital at home.

• Step up/down care.

• Virtual wards.

• Rapid responses schemes (no evidence available).

The studies in the reviews have been classified into 2 strata depending on the main purpose of the intervention; admission avoidance and early discharge.

– Admission avoidance: where a service that provides active treatment by health care professionals outside hospital for a condition that otherwise would require acute hospital in-patient admission. Patients may avoid admission to an acute hospital ward after receiving community based care.

– Early discharge: where a service that provides active treatment by health care professionals outside hospital for a condition that otherwise would require continued acute hospital in-patient care. Patients may be discharged early from hospital to receive care in the community.

Hospital at home

There was evidence from 36 RCTs comparing hospital at home (led by primary care, secondary care or both primary and secondary care), step-up/down care and virtual wards. The studies were categorised into 2 strata: hospital at home services focussing on early discharge and hospital at home services focussing on admission avoidance. Within each category, the evidence was classified into hospital at home led by primary care, hospital at home led by secondary care, hospital at home led by primary and secondary care, step up/down care and virtual wards.

Stratum – Early discharge

Hospital at home led by primary care

Six studies evaluated hospital at home led by primary care compared to usual hospital care. The evidence suggested that hospital at home led by primary care may provide a benefit in reduced admissions, presentations to ED, hospital length of stay, quality of life and patient satisfaction. The evidence suggested that there was no effect on mortality and there was reduced carer satisfaction in hospital at home led

a NICE has published guidelines on transition between inpatient hospital settings and community or care home settings

for adults with social care needs and intermediate care including reablement





by primary care compared to usual hospital care. No evidence was identified for avoidable adverse events, GP presentations or readmissions.

Hospital at home led by secondary care

Two studies evaluated hospital at home led by secondary care compared to usual hospital care. The evidence suggested that hospital at home led by secondary care may provide a benefit in reduced re-admissions. However, there was a possible increase in mortality. No evidence was identified for avoidable adverse events, quality of life, patient satisfaction, length of stay, length of stay in programme, presentation to ED, admissions and GP presentations.

Hospital at home led by both primary and secondary care

Five studies evaluated hospital at home led by both primary and secondary care compared to usual hospital care. The evidence showed a benefit in reduced admissions, and carer satisfaction compared to hospital care. The evidence suggested that there was no effect on mortality. There was an increase in re-admissions (30 days) and length of stay (days in treatment) in hospital at home led primary and secondary care compared to usual hospital care. Evidence on quality of life and on patient satisfaction was either neutral or suggested a trend for improvement. No evidence was identified for avoidable adverse events, length of stay in programme, presentation to ED and presentation to GP.

Step-up/down care

Three studies evaluated step-up/down care compared to hospital care. The evidence suggested that step-up/down care may provide a benefit in reduced mortality and readmissions compared to hospital care. There was a suggested increase in length of stay (initial inpatient days) in step-up down care compared to hospital care.

No evidence was identified for avoidable adverse events, quality of life, patient satisfaction, length of stay in programme, number of presentations to ED, number of GP presentations and admissions.

Virtual wards

One study evaluated virtual wards compared to hospital care. The evidence suggested that virtual wards may provide a benefit in reduced mortality compared to hospital care but there was no effect on quality of life. No evidence was identified for avoidable adverse events, patient satisfaction, length of hospital stay, length of stay in programme, number of presentation to ED, number of admissions to hospital, number of GP presentation and readmission.

Stratum – Admission avoidance

There was variation in how these diverse admission avoidance schemes operated. Some schemes admitted patients directly from the community and some from the emergency department.

The majority of the trials included in the admission avoidance strata recruited elderly patients with medical events like stroke and COPD requiring admission to hospital.





The committee considered that avoiding readmission was likely to be particularly important for people with chronic conditions as in this group hospital admission might have a disproportionately adverse effect on psychological wellbeing and independence.

Hospital at home led by primary care

Four studies evaluated the role of hospital at home led by primary care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that hospital at home led by primary care may provide a benefit in reduced mortality and quality of life on SF-12physical scores. The evidence suggested that there was no effect on days to discharge. There was an increase in readmissions under 30 days, adverse events and reduced patient satisfaction in hospital at home led by primary care compared to hospital care. No difference was identified for admissions over 30 days and quality of life on SF-12 mental scores. Hospital at home led by secondary care Four studies evaluated hospital at home led by secondary care compared to hospital care. The evidence suggested that hospital at home led by secondary care may provide a benefit in reduced mortality, admissions (>30 days), improved patient satisfaction and quality of life compared to hospital care. The evidence suggested that there was increased length of stay in hospital at home led by secondary care compared to hospital care. No evidence was identified for avoidable adverse events, length of stay in programme, number of presentations to ED, number of GP presentations and readmission. Hospital at home led by both primary and secondary care Two studies evaluated hospital at home led by both primary and secondary care compared to hospital care. The evidence suggested that hospital at home led by primary and secondary care may provide a benefit in improved patient satisfaction, carer satisfaction and reduced adverse events compared to hospital care. There was a possible increase in mortality, admissions (>30 days) and reduced quality of life in hospital at home led by primary and secondary care compared to hospital care. No evidence was identified for length of stay, length of stay in programme, number of presentations to ED, number of GP presentation and readmission. Step-up down care One study evaluated step-up/down care compared to hospital care. The evidence suggested step-up/down care may provide a benefit in reduced mortality and length of stay compared to hospital care. No evidence was identified for avoidable adverse events, quality of life, patient satisfaction, length of stay in programme, number of presentations to ED, number of GP presentations and readmissions. Virtual wards One study evaluated virtual wards compared to hospital care. The evidence suggested that virtual wards provide a benefit in reduced mortality, reduced re-admissions (30 days) and presentations to ED compared to hospital care. No





evidence was identified for avoidable adverse events, quality of life, patient satisfaction, length of hospital stay, length of stay in programme, number of admissions to hospital and number of GP presentations. Rapid response schemes

No evidence was available to evaluate rapid response schemes.

Overall

The committee chose to recommend alternatives to hospital care given the potential benefits in patient and carer satisfaction, facilitation of early discharge and prevention of hospital admission, if there is a discussion of the potential benefits and risks with the patient and their carer. The committee also concluded that RCT evidence supported the concept that, with appropriate patient selection, hospital at home schemes could be considered safe.

The committee discussed what type of alternatives to hospital care should be recommended: hospital at home, community-based intermediate care or community-based care. This review did not search for data that specifically compared different schemes. The committee agreed that service development would need to be undertaken collaboratively between primary and secondary care.

The committee noted that ‘hospital-at-home’ was not easily defined and that there were some regions in which community-based intermediate care could differ. Therefore, the committee chose to recommend community-based intermediate care generally, rather than specifying the precise content of the various interventions.

The committee also noted that there were many different schemes and with different names, which could be confusing for the patient as well as the service provider. It was however felt that, despite this, if one concentrated on what each individual scheme provided to the patient then they were very similar. They generally involved nurses and/or therapists with medical support providing nursing care, rehabilitative therapy, education and support to a patient in the community with an aim to promote independence, prevent admission and facilitate discharge. Indeed, it was felt that if the names of the services were simplified under 1 heading, it would be much easier to understand and the focus could be on the level of support and care the patient required.

The committee wished to clarify that community-based care should only be provided where equivalent care could be provided in a non-hospital based setting and following appropriate risk stratification using appropriate diagnostics, clinical presentation, patient preference, history and safety netting. The committee noted that there were some groups of people (for example, people with life threatening conditions such as acute myocardial infarction) in whom the provision of care in a non-hospital based setting was not appropriate in the acute stage.

Trade-off between net effects and costs

Hospital at home

Eleven economic evaluations were included covering the 3 models of hospital at home (secondary care-led, primary care-led and mixed model). This evidence consistently showed that hospital at home schemes can be provided at a lower cost for a variety of patient groups. Seven studies showed that hospital at home was





dominant when compared to inpatient care, where it appeared to improve outcomes as well as lower costs. This was the case for all three of the full economic evaluations of interventions combining both admission avoidance and early discharge. In the remaining three studies, the health benefit for hospital care was small and did not appear to be cost effective. Cost savings were greatest for those interventions that included admission avoidance.

The committee highlighted the importance of assessing patients’ risk before referring them to be cared for under a hospital-at home service, which was in line with the inclusion criteria of the included studies. The committee also highlighted the importance of providing 24-hour access to care for hospital-at-home patients as currently available hospital-at-home services differ in terms of the hours that they operate. For example, the committee noted that most of the included studies provided 24-hour access to the service, either in person or via phone. The provision of these services across a 24 hour, 7-day period may affect cost in terms of both staff costs as well as its impact on patients’ safety and efficacy. Anecdotally, the committee noted that many schemes provided extended day hours or 24 hours a day but services are shared with other out-of-hour services.

Step up/step-down models

One economic evaluation showed that care in a community hospital was cost effective compared to inpatient care, at a cost of £16,400 per QALY gained, which is below the NICE threshold. A cost simulation study showed that long-term costs were lower but it would take more than 5 years to break even because of the time taken to build up credibility and reach optimal scale.

Virtual wards

One cost simulation study showed that long-term costs were lower but it would take about 5 years to break even.

Rapid response schemes

A cost simulation study showed that long-term costs were lower but it would take more than 5 years to break even.

Quality of evidence Overall, the quality of the evidence was graded from very low to high. Evidence was downgraded and this was mainly due to risk of bias, imprecision and inconsistency.

The economic evidence for hospital at home was rated as partially applicable with potentially serious limitations, since QALYs were rarely measured, only two studies were set in the UK and the effectiveness evidence was not based on a systematic review.

Other considerations The committee highlighted that they were aware of observational studies of alternatives to hospital care but wished to prioritise the inclusion of higher quality, RCT evidence for inclusion in the review.

The committee emphasised that where possible, decisions about treatment location should be made collaboratively with the patient. It was noted that patient acceptability would need to be determined on a case by case basis. It is important that patients should be involved in discussions of risks and benefits.

Overall it was felt the provision of intermediate care as an alternative to hospital admission should be supported and developed in view of the evidence reviewed. It





also fits with the NHS Five Year Forward View by providing more care in the community, but supported by primary and secondary care in an integrated way. The health economic data suggests that this model of care may be cost saving which is another important issue for the NHS in the ensuing years. Although it is likely that in the initial phase in development or expansion of schemes they may be costlier and will take some years to break even, and then become cost saving as some of the economic evidence showed. One barrier to the development of this model of care could be the conflict between primary and secondary care. The skills and resources of both sectors and the third sector (voluntary) will need to be harnessed for such models of care to work. It is also important that areas of good practice are shared. Simplification of delivery of intermediate care would also be of use; rather than focussing on the title of the service, it would be better if the needs of the patient are the focus of delivery of care. This would probably allow services between regions to be compared with each other and benchmarking of services.

The National Audit of Intermediate Care214 defines intermediate care in 4 categories:

• Crisis response.

• Home-based intermediate care.

• Bed-based intermediate care.

• Reablement.

The committee discussed existing guidance from NICE on social care and felt is was appropriate to cross reference the following guideline:

• Transition between inpatient hospital settings and community or care home

settings for adults with social care needs (2015).210

• Older people with social care needs and multiple long-term conditions

(2015).209

• Transition between inpatient mental health settings and community or care

home settings (2016).212

• Home care: delivering personal care and practical support to older people

living in their own homes (2015).208

• Intermediate care including reablement (2017).213–

• Managing medicines for adults receiving social care in the community (2017).211



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287 Teng J, Mayo NE, Latimer E, Hanley J, Wood-Dauphinee S, Cote R et al. Costs and caregiver consequences of early supported discharge for stroke patients. Stroke. 2003; 34(2):528-536

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289 Thomas DR, Brahan R, Haywood BP. Inpatient community-based geriatric assessment reduces subsequent mortality. Journal of the American Geriatrics Society. 1993; 41(2):101-104

290 Thomas JA. Hospital in the home: a randomised controlled trial. Medical Journal of Australia. 1999; 171(2):110-111

291 Thorne D, Jeffery S. Intermediate care. Homeward bound. Health Service Journal. 2001; 111(5785):28-29

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Appendices

Appendix A: Review protocol

Table 11: Review protocol: Alternatives to hospital care

Review question Alternatives to hospital care

Guideline condition and its definition

Acute Medical Emergencies. Definition: a medical emergency can arise in anyone, for example, in people without a previously diagnosed medical condition, with an acute exacerbation of underlying chronic illness, after surgery or after trauma.

Objectives To determine if wider provision of community-based intermediate care prevents people from staying in hospitals longer than necessary while not impacting on patient and carer outcomes.

Review population Adults and young people (16 years and over) with a suspected or confirmed AME or patients at risk of AME.

Adults (17 years and above). Young people (aged 16-17 years).

Line of therapy not an inclusion criterion.

Interventions and comparators: generic/class; specific/drug (All interventions will be compared with each other, unless otherwise stated)

Hospital at home; hospital at home led by primary care. Hospital at home; hospital at home led by secondary care. Step up/down care; step up/down care. Rapid response schemes. Virtual wards. Hospital-based care/services. Usual Care.

Outcomes - Quality of life at during study period (Continuous) CRITICAL - Length of hospital stay at during study period (Continuous) IMPORTANT - Mortality at during study period (Dichotomous) CRITICAL - Avoidable adverse events at during study period (Dichotomous) CRITICAL - Patient and/or carer satisfaction at during study period (Dichotomous) CRITICAL - Number of presentations to Emergency Department at during study period (Dichotomous) IMPORTANT - Number of admissions to hospital at after 30 days of first admission (Dichotomous) CRITICAL - Number of GP presentations at during study period (Dichotomous) IMPORTANT - Readmission up to 30 days (Dichotomous) IMPORTANT

Study design Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified.

Unit of randomization Patient.

Crossover study Permitted.

Minimum duration of study Not defined.

Stratification Early discharge. Admission avoidance.

Reasons for stratification Each of them targets a separate outcome: early discharge would be primarily aimed at reducing length of stay, while admission avoidance would be primarily aimed at reducing hospital admission. Also, the population would be different as the admission avoidance group could be managed at home for the whole



episode of care (they could be cared for at home from the start) while the early discharge group needs to be “stabilised” at hospital first then discharged.

Subgroup analyses if there is heterogeneity

- Frail elderly (frail elderly; not frail elderly); different from younger population.

Search criteria Databases: Medline, Embase, the Cochrane Library. Date limits for search: none. Language: English.



Appendix B: Clinical article selection

Figure 1: Flow chart of clinical article selection for the review of alternatives to hospital care

Records screened,

• hospital at home, n= 3420

• virtual wards, n=236

Records excluded,

• Hospital at home, n= 3131


Studies included in review,



Studies excluded from review,

• Hospital at home, n=234


Reasons for exclusion: see Appendix H

Records identified through database searching,



Additional records identified through other sources,



Full-text articles assessed for eligibility,





Appendix C: Forest plots

C.1.1 Early discharge

Figure 2: Mortality- Early discharge

Study or Subgroup

1.1.1 Hospital at home led by primary care

Cotton 2000

Hernandez 2003

Ojoo 2002

Shepperd 1998

Utens 2012Subtotal (95% CI)

Total events

Heterogeneity: Chi² = 3.61, df = 4 (P = 0.46); I² = 0%

Test for overall effect: Z = 0.33 (P = 0.74)

1.1.2 Hospital at home led by secondary care

Patel 2008Subtotal (95% CI)

Total events

Heterogeneity: Not applicable


1.1.3 Hospital at home led by both primary and secondary care

Donald 1995

Harris 2005

Nikolaus 1999

Skwarska 2000Subtotal (95% CI)

Total events



1.1.4 Step up/down care

Garasen 2007

Herfjord 2014

Young 2007Subtotal (95% CI)

Total events



1.1.5 virtual wards

Jakobsen 2015Subtotal (95% CI)

Total events



Events

1

5

1

9

1

17

2

2

9

10

33

4

56

9

42

73

124

3

3

Total

41

121

30

47

70309

1313

30

143

181

122476

72

190

280542

2929

Events

2

7

3

4

1

17

2

2

5

8

32

7

52

14

40

64

118

4

4

Total

40

101

30

42

69282

1818

30

142

185

62419

70

186

210466

2828

Weight

11.3%

42.7%

16.8%

23.6%

5.6%100.0%

100.0%100.0%

9.3%

14.9%

58.7%

17.2%100.0%

11.1%

31.6%

57.2%100.0%

100.0%100.0%

M-H, Fixed, 95% CI

0.49 [0.05, 5.17]

0.60 [0.20, 1.82]

0.33 [0.04, 3.03]

2.01 [0.67, 6.05]

0.99 [0.06, 15.45]0.90 [0.47, 1.71]

1.38 [0.22, 8.59]1.38 [0.22, 8.59]

1.80 [0.68, 4.74]

1.24 [0.50, 3.05]

1.05 [0.68, 1.64]

0.29 [0.09, 0.95]1.02 [0.72, 1.44]

0.63 [0.29, 1.35]

1.03 [0.70, 1.51]

0.86 [0.64, 1.14]0.88 [0.71, 1.10]

0.72 [0.18, 2.95]0.72 [0.18, 2.95]

Alternatives Hospital care Risk Ratio Risk Ratio

M-H, Fixed, 95% CI

0.05 0.2 1 5 20Favours Alternatives Favours Hospital Care



Figure 3: Readmissions (30 days) - Early discharge

Figure 4: Admissions - Early discharge

Figure 5: Presentations to ED - Early discharge

Study or Subgroup

1.2.1 Hosital at home led by secondary care

Ince 2014Subtotal (95% CI)

Total events




Harris 2005Subtotal (95% CI)

Total events




Garasen 2007Subtotal (95% CI)

Total events



Events

1

1

30

30

14

14

Total

4242

143143

7272

Events

2

2

18

18

25

25

Total

4242

142142

7070

Weight

100.0%100.0%

100.0%100.0%

100.0%100.0%

M-H, Fixed, 95% CI

0.50 [0.05, 5.31]0.50 [0.05, 5.31]

1.66 [0.97, 2.83]1.66 [0.97, 2.83]

0.54 [0.31, 0.96]0.54 [0.31, 0.96]


M-H, Fixed, 95% CI


Study or Subgroup


Cotton 2000

Hernandez 2003

Ojoo 2002

Rich 1993

Shepperd 1998

Utens 2012Subtotal (95% CI)

Total events




Bowler 2001

Donald 1995

Harris 2005

Nikolaus 1999

Skwarska 2000Subtotal (95% CI)

Total events



Events

12

23

10

21

13

17

96

6

9

14

43

27

99

Total

41

121

30

63

38

24317

13

30

143

140

122448

Events

12

26

13

16

5

17

89

2

6

15

45

21

89

Total

40

101

30

35

37

25268

12

30

142

141

62387

Weight

12.7%

29.6%

13.6%

21.5%

5.3%

17.4%100.0%

2.2%

6.3%

15.7%

46.8%

29.1%100.0%

M-H, Fixed, 95% CI

0.98 [0.50, 1.91]

0.74 [0.45, 1.21]

0.77 [0.40, 1.47]

0.73 [0.44, 1.20]

2.53 [1.00, 6.40]

1.04 [0.72, 1.51]0.92 [0.73, 1.15]

2.77 [0.69, 11.17]

1.50 [0.61, 3.69]

0.93 [0.46, 1.85]

0.96 [0.68, 1.36]

0.65 [0.40, 1.06]0.94 [0.74, 1.20]


M-H, Fixed, 95% CI

0.1 0.2 0.5 1 2 5 10Favours Alternatives Favours Hospital Care

Study or Subgroup


Hernandez 2003Subtotal (95% CI)

Total events



Events

11

11

Total

121121

Events

21

21

Total

101101

Weight

100.0%100.0%

M-H, Fixed, 95% CI

0.44 [0.22, 0.86]0.44 [0.22, 0.86]


M-H, Fixed, 95% CI




Figure 6: Length of stay (initial inpatient days) - Early discharge

Figure 7: Length of stay (days in treatment) - Early discharge

Study or Subgroup


Hernandez 2003

Subtotal (95% CI)


Test for overall effect: Z = 5.31 (P < 0.00001)


Garasen 2007

Herfjord 2014

Subtotal (95% CI)



Mean

1.71

17.5

10.4

SD

2.33

12.341

15.8

Total

121

121

72

190

262

Mean

4.15

9.1

10.5

SD

4.1

9.2266

15.2

Total

101

101

70

186

256

Weight

100.0%

100.0%

43.4%

56.6%

100.0%

IV, Fixed, 95% CI

-2.44 [-3.34, -1.54]

-2.44 [-3.34, -1.54]

8.40 [4.82, 11.98]

-0.10 [-3.23, 3.03]

3.59 [1.23, 5.95]

Alternatives Hospital care Mean Difference Mean Difference

IV, Fixed, 95% CI

-20 -10 0 10 20

Favours Alternatives Favours Hospital Care

Study or Subgroup

1.6.1 Hospital at led by primary and secondary care

Harris 2005

Subtotal (95% CI)



Mean

8.8

SD

4.3

Total

143

143

Mean

5.7

SD

6.6

Total

142

142

Weight

100.0%

100.0%

IV, Fixed, 95% CI

3.10 [1.81, 4.39]

3.10 [1.81, 4.39]


IV, Fixed, 95% CI

-20 -10 0 10 20




Figure 8: Quality of life(high score is good) - Early discharge

Figure 9: Quality of life (higher values better QoL) - Early discharge

Study or Subgroup

1.9.1 HAH led by primary care (SGRQ; change score; reversed)

Hernandez 2003

Ojoo 2002

Subtotal (95% CI)



1.9.2 HAH led by primary care (EQ-5D; change score)

Utens 2012

Subtotal (95% CI)



1.9.3 Virtual wards (EQ-5D summary index;change score)

Jakobsen 2015

Subtotal (95% CI)



1.9.4 HAH led by primary and secondary care (final score; SF-36; physical)

Harris 2005

Subtotal (95% CI)



1.9.5 HAH led by primary and secondary care (final score; SF-36; mental)

Harris 2005

Subtotal (95% CI)



Mean

6.9

12.1

0.008

0.1

34.8

53.4

SD

16.9413

17.3

0.2866

0.12

10.7

10.5

Total

121

30

151

54

54

29

29

121

121

121

121

Mean

2.4

11.6

-0.036

0.1

34.4

52.1

SD

16.9413

12.8

0.3064

0.4

9.9

12

Total

101

30

131

47

47

28

28

120

120

120

120

Weight

74.8%

25.2%

100.0%

100.0%

100.0%

100.0%

100.0%

100.0%

100.0%

100.0%

100.0%

IV, Fixed, 95% CI

4.50 [0.02, 8.98]

0.50 [-7.20, 8.20]

3.49 [-0.38, 7.36]

0.04 [-0.07, 0.16]

0.04 [-0.07, 0.16]

0.00 [-0.15, 0.15]

0.00 [-0.15, 0.15]

0.40 [-2.20, 3.00]

0.40 [-2.20, 3.00]

1.30 [-1.55, 4.15]

1.30 [-1.55, 4.15]


IV, Fixed, 95% CI

-20 -10 0 10 20

Favours Hospital Care Favours Alternatives

Study or Subgroup

1.10.1 HAH led by primary care (COOP chart; change score; reversed)

Shepperd 1998

Subtotal (95% CI)



Total (95% CI)



Test for subgroup differences: Not applicable

Mean

-0.16

SD

1.1266

Total

38

38

38

Mean

-0.35

SD

1.1266

Total

37

37

37

Weight

100.0%

100.0%

100.0%

IV, Fixed, 95% CI

0.17 [-0.29, 0.62]

0.17 [-0.29, 0.62]

0.17 [-0.29, 0.62]

Alternatives Hospital care Std. Mean Difference Std. Mean Difference

IV, Fixed, 95% CI

-1 -0.5 0 0.5 1




Figure 10: Patient satisfaction (dichotomous) - Early discharge

Figure 11: Patient Satisfaction (continuous-higher values more satisfied) - Early discharge

Figure 12: Carer satisfaction (dichotomous) - Early discharge

Study or Subgroup

1.12.1 Hospital at home led by Primary care

Ojoo 2002Subtotal (95% CI)

Total events





Total events



Events

25

25

93

93

Total

2727

112112

Events

24

24

87

87

Total

2727

120120

Weight

100.0%100.0%

100.0%100.0%

M-H, Fixed, 95% CI

1.04 [0.88, 1.24]1.04 [0.88, 1.24]

1.15 [1.00, 1.32]1.15 [1.00, 1.32]


M-H, Fixed, 95% CI

0.5 0.7 1 1.5 2Favours Hospital Care Favours Alternatives

Study or Subgroup


Hernandez 2003

Utens 2012

Subtotal (95% CI)



1.15.2 Hospital at home led by primary and secondary care

Nikolaus 1999

Subtotal (95% CI)



Mean

8

71

3.9

SD

1.698411

12.5

2.843387

Total

121

29

150

140

140

Mean

7.5

70

3.2

SD

1.698411

12.7

2.843387

Total

101

34

135

141

141

Weight

77.7%

22.3%

100.0%

100.0%

100.0%

IV, Fixed, 95% CI

0.29 [0.03, 0.56]

0.08 [-0.42, 0.57]

0.25 [0.01, 0.48]

0.25 [0.01, 0.48]

0.25 [0.01, 0.48]


IV, Fixed, 95% CI

-4 -2 0 2 4


Study or Subgroup


Ojoo 2002Subtotal (95% CI)

Total events





Total events



Events

18

18

46

46

Total

2020

6969

Events

13

13

24

24

Total

1414

5858

Weight

100.0%100.0%

100.0%100.0%

M-H, Fixed, 95% CI

0.97 [0.79, 1.19]0.97 [0.79, 1.19]

1.61 [1.14, 2.28]1.61 [1.14, 2.28]


M-H, Fixed, 95% CI

0.2 0.5 1 2 5Favours Hospital Care Favours Alternatives



C.1.2 Admission avoidance

Figure 13: Mortality - Admission avoidance

Figure 14: Readmissions (< 30 days) - Admission avoidance

Study or Subgroup


Talcott 2011

Wilson 1999Subtotal (95% CI)

Total events




Aimonino 2008

Mendoza 2009

Tibaldi 2009

Vianello 2013ASubtotal (95% CI)

Total events




Davies 2000Subtotal (95% CI)

Total events



1.18.4 Virtual wards

Dhalla 2014Subtotal (95% CI)

Total events




Applegate 1990Subtotal (95% CI)

Total events



Events

0

26

26

9

2

7

3

21

9

9

40

40

8

8

Total

47

102149

52

37

48

26163

100100

958958

7878

Events

0

30

30

12

3

8

4

27

4

4

47

47

16

16

Total

66

97163

52

34

53

27166

5050

955955

7777

Weight

100.0%100.0%

45.0%

11.7%

28.5%

14.7%100.0%

100.0%100.0%

100.0%100.0%

100.0%100.0%

M-H, Fixed, 95% CI

Not estimable

0.82 [0.53, 1.29]0.82 [0.53, 1.29]

0.75 [0.35, 1.63]

0.61 [0.11, 3.45]

0.97 [0.38, 2.46]

0.78 [0.19, 3.15]0.80 [0.47, 1.35]

1.13 [0.36, 3.47]1.13 [0.36, 3.47]

0.85 [0.56, 1.28]0.85 [0.56, 1.28]

0.49 [0.22, 1.09]0.49 [0.22, 1.09]


M-H, Fixed, 95% CI


Study or Subgroup


Corwin 2005

Talcott 2011Subtotal (95% CI)

Total events





Total events



Events

11

4

15

182

182

Total

98

47145

961961

Events

3

0

3

204

204

Total

96

66162

958958

Weight

87.9%

12.1%100.0%

100.0%100.0%

M-H, Fixed, 95% CI

3.59 [1.03, 12.48]

12.56 [0.69, 227.89]4.68 [1.53, 14.31]

0.89 [0.74, 1.06]0.89 [0.74, 1.06]


M-H, Fixed, 95% CI




Figure 15: Admissions(>30 days) - Admission avoidance

Figure 16: Presentations to ED - Admission avoidance

Figure 17: Length of stay (initial inpatient days) - Admission avoidance

Study or Subgroup


Richards 2005

Wilson 1999Subtotal (95% CI)

Total events




Aimonino 2008

Mendoza 2009

Tibaldi 2009Subtotal (95% CI)

Total events




Caplan 2005

Davies 2000Subtotal (95% CI)

Total events



Events

2

21

23

17

15

8

40

7

37

44

Total

24

101125

41

37

48126

51

100151

Events

1

16

17

34

17

18

69

5

17

22

Total

25

96121

39

34

53126

49

5099

Weight

5.6%

94.4%100.0%

50.0%

25.4%

24.6%100.0%

18.4%

81.6%100.0%

M-H, Fixed, 95% CI

2.08 [0.20, 21.50]

1.25 [0.69, 2.24]1.29 [0.73, 2.29]

0.48 [0.32, 0.70]

0.81 [0.48, 1.36]

0.49 [0.24, 1.02]0.56 [0.42, 0.75]

1.35 [0.46, 3.96]

1.09 [0.68, 1.73]1.14 [0.74, 1.74]


M-H, Fixed, 95% CI


Study or Subgroup



Total events



Events

270

270

Total

961961

Events

284

284

Total

959959

Weight

100.0%100.0%

M-H, Fixed, 95% CI

0.95 [0.82, 1.09]0.95 [0.82, 1.09]


M-H, Fixed, 95% CI

0.5 0.7 1 1.5 2Favours Alternatives Favours Hospital Care

Study or Subgroup


Applegate 1990

Subtotal (95% CI)



Mean

18.6

SD

12.2

Total

78

78

Mean

22.7

SD

16

Total

77

77

Weight

100.0%

100.0%

IV, Fixed, 95% CI

-4.10 [-8.58, 0.38]

-4.10 [-8.58, 0.38]


IV, Fixed, 95% CI

-20 -10 0 10 20




Figure 18: Length of stay (days in treatment) - Admission avoidance

Figure 19: Quality of life (high score is good) - Admission avoidance

Study or Subgroup


Mendoza 2009

Tibaldi 2009Subtotal (95% CI)



Mean

10.9

20.7

SD

5.9

6.9

Total

37

4885

Mean

7.9

11.6

SD

3

10.7

Total

34

5387

Weight

72.3%

27.7%100.0%

IV, Fixed, 95% CI

3.00 [0.85, 5.15]

9.10 [5.62, 12.58]4.69 [2.86, 6.52]


IV, Fixed, 95% CI

-20 -10 0 10 20Favours Alternatives Favours Hospital Care

Study or Subgroup

1.26.1 HAH led by primary care (final score; SF-12; physical)

Richards 2005

Subtotal (95% CI)



1.26.2 HAH led by primary care (final score; SF-12; mental)

Richards 2005

Subtotal (95% CI)



1.26.3 HAH led by secondary care (NHP, change score; reversed)

Aimonino 2008

Tibaldi 2009

Subtotal (95% CI)



1.26.4 HAH led by secondary care (change score; SF-36; physical)

Mendoza 2009

Subtotal (95% CI)



1.26.5 HAH led by secondary care (change score; SF-36; mental)

Mendoza 2009

Subtotal (95% CI)



1.26.6 HAH led by primary and secondary care (SGRQ; change score; reversed)

Davies 2000

Subtotal (95% CI)



Mean

42.2

50.4

3.6

1.09

3.6

4

0.48

SD

9.255882

8.683658

7.9

2.57

8.111732

5.71682

16.92

Total

24

24

24

24

52

48

100

37

37

37

37

34

34

Mean

45.8

51

0.8

0.18

2.2

2.8

3.31

SD

9.255882

8.683658

4.5

1.94

8.111732

5.71682

14.02

Total

25

25

25

25

52

53

105

34

34

34

34

16

16

Weight

100.0%

100.0%

100.0%

100.0%

11.6%

88.4%

100.0%

100.0%

100.0%

100.0%

100.0%

100.0%

100.0%

IV, Fixed, 95% CI

-3.60 [-8.78, 1.58]

-3.60 [-8.78, 1.58]

-0.60 [-5.46, 4.26]

-0.60 [-5.46, 4.26]

2.80 [0.33, 5.27]

0.91 [0.01, 1.81]

1.13 [0.29, 1.97]

1.40 [-2.38, 5.18]

1.40 [-2.38, 5.18]

1.20 [-1.46, 3.86]

1.20 [-1.46, 3.86]

-2.83 [-11.75, 6.09]

-2.83 [-11.75, 6.09]


IV, Fixed, 95% CI

-20 -10 0 10 20




Figure 20: Patient satisfaction (dichotomous) - Admission avoidance

Figure 21: Patient Satisfaction (continuous-higher score is good) - Admission avoidance

Figure 22: Days to discharge (hazard ratio) - Admission avoidance

Figure 23: Carer satisfaction (continuous) - Admission avoidance

Study or Subgroup

1.28.1 Hospital at home led by Primary care

Corwin 2005Subtotal (95% CI)

Total events




Aimonino 2008Subtotal (95% CI)

Total events



Events

87

87

49

49

Total

9191

5252

Events

87

87

46

46

Total

8888

5252

Weight

100.0%100.0%

100.0%100.0%

M-H, Fixed, 95% CI

0.97 [0.92, 1.02]0.97 [0.92, 1.02]

1.07 [0.95, 1.20]1.07 [0.95, 1.20]


M-H, Fixed, 95% CI

0.5 0.7 1 1.5 2Favours Hospital Care Favours Alternatives

Study or Subgroup

1.29.1 Hospital at home led by primary and secondary care (reversed scale)

Caplan 2005

Subtotal (95% CI)



Mean

3.9

SD

0.3127

Total

40

40

Mean

3

SD

0.641

Total

20

20

Weight

100.0%

100.0%

IV, Fixed, 95% CI

1.98 [1.33, 2.64]

1.98 [1.33, 2.64]


IV, Fixed, 95% CI

-4 -2 0 2 4


Study or Subgroup

1.30.1 Hospital at Home Primary Care (Hazard Ratio)

Corwin 2005

Subtotal (95% CI)



log[Hazard Ratio]

-0.0513

SE

0.1486

Total

98

98

Total

96

96

Weight

100.0%

100.0%

IV, Fixed, 95% CI

0.95 [0.71, 1.27]

0.95 [0.71, 1.27]

Alternatives Hospital care Hazard Ratio Hazard Ratio

IV, Fixed, 95% CI

0.5 0.7 1 1.5 2


Study or Subgroup

1.33.1 Hospital at home led by primary and secondary care

Caplan 2005

Subtotal (95% CI)



Mean

3.9

SD

0.2579

Total

28

28

Mean

3.1

SD

0.8274

Total

13

13

Weight

100.0%

100.0%

IV, Fixed, 95% CI

1.55 [0.80, 2.29]

1.55 [0.80, 2.29]


IV, Fixed, 95% CI

-2 -1 0 1 2




Figure 24: Adverse events – Admission avoidance

C.1.3 Individual patient data analyses

Figure 25: IPD generic inverse variance early discharge elderly medical mortality at 3 months

Figure 26: IPD generic inverse variance early discharge readmission at 3 months

Figure 27: Readmission 3 months (excluding readmissions in the first 14 days)

Study or Subgroup


Richards 2005Subtotal (95% CI)

Total events




Caplan 2005Subtotal (95% CI)

Total events



Events

10

10

6

6

Total

2424

5151

Events

8

8

8

8

Total

2525

4949

Weight

100.0%100.0%

100.0%100.0%

M-H, Fixed, 95% CI

1.30 [0.62, 2.73]1.30 [0.62, 2.73]

0.72 [0.27, 1.93]0.72 [0.27, 1.93]


M-H, Fixed, 95% CI


Study or Subgroup

2.1.1 Mortality at 3 months in older patients with a mix of conditions (Martin at 6 months)

Cunliffe 2004

Harris 2005

Martin 1994

Richards 1998

Shepperd 1998Subtotal (95% CI)



Total (95% CI)



Test for subgroup differences: Not applicable

log[Mortality]

-0.13

0.229

-0.21

-0.318

0.617

SE

0.344

0.475

0.817

0.527

0.508

Total

185

104

29

143

63524

524

Total

185

105

25

76

63454

454

Weight

38.7%

20.3%

6.9%

16.5%

17.7%100.0%

100.0%

IV, Fixed, 95% CI

0.88 [0.45, 1.72]

1.26 [0.50, 3.19]

0.81 [0.16, 4.02]

0.73 [0.26, 2.04]

1.85 [0.68, 5.02]1.04 [0.68, 1.58]

1.04 [0.68, 1.58]

Hospital at home Inpatient care Mortality Mortality

IV, Fixed, 95% CI

0.001 0.1 1 10 1000Favours treatment Favours control

Study or Subgroup

Cunliffe 2004

Harris 2005

Shepperd 1998

Total (95% CI)



log[Readmission]

0.226

0.996

0.867

SE

0.213

0.677

0.384

Total

185

104

63

352

Total

185

105

63

353

Weight

71.1%

7.0%

21.9%

100.0%

IV, Fixed, 95% CI

1.25 [0.83, 1.90]

2.71 [0.72, 10.21]

2.38 [1.12, 5.05]

1.52 [1.07, 2.16]

Hospital at home Inpatient care Readmission Readmission

IV, Fixed, 95% CI


Study or Subgroup

Davies 2000

Harris 2005

Wilson 1999

Total (95% CI)



log[Readmission]

0.241

0.6729

0.452

SE

0.336

1.225

0.383

Weight

54.2%

4.1%

41.7%

100.0%

IV, Fixed, 95% CI

1.27 [0.66, 2.46]

1.96 [0.18, 21.63]

1.57 [0.74, 3.33]

1.41 [0.87, 2.30]

Readmission Readmission

IV, Fixed, 95% CI




Figure 28: Mortality 3 months

Study or Subgroup

Davies 2000

Harris 2005

Kalra 2000

Ricauda 2004

Wilson 1999

Total (95% CI)



log[Mortality]

-0.096

2.0202

-0.343

-0.244

-0.185

SE

0.627

1.4285

0.392

0.339

0.2723

Weight

8.0%

1.5%

20.5%

27.4%

42.5%

100.0%

IV, Fixed, 95% CI

0.91 [0.27, 3.10]

7.54 [0.46, 123.97]

0.71 [0.33, 1.53]

0.78 [0.40, 1.52]

0.83 [0.49, 1.42]

0.82 [0.58, 1.17]

Mortality Mortality

IV, Fixed, 95% CI


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Appendix D: Clinical evidence tables

D.1.1 Cochrane Review

Study Herfjord 2014140

Study type RCT (Patient randomised; Parallel).

Number of studies (number of participants) 1 (n=400).

Countries and setting Conducted in Norway.

Line of therapy Not applicable.

Duration of study Intervention + follow up: intervention 3 weeks +1 year follow-up.

Method of assessment of guideline condition Adequate method of assessment/diagnosis.

Stratum Early discharge.

Subgroup analysis within study Not applicable.

Inclusion criteria Patients admitted acutely from home to medical or orthopaedic departments if they were a resident of the municipality, aged 70 years or older; respiratory and circulatory stable and deemed able to return home within three weeks.

Exclusion criteria Severe dementia, delirium, any need for surgery or intensive care treatment.

Recruitment/selection of patients Suitable patients were invited to participate in the trial if attending physician considered intermediate care an appropriate treatment option, and if randomisation could take place within the first 72 hours after admission.

Age, gender and ethnicity Age - Mean (range): Intervention group- 83.6 (70-96); 84.6 (71-98). Gender (M:F): Females %: intervention group-73.2%; control group-73.7%. Ethnicity: not stated

Further population details Not stated.

Indirectness of population No indirectness.

Interventions (n=200) Intervention 1: Hospital at home - Hospital at home led by primary care. The intervention included rapid transfer to intermediate care unit in a nursing home. The unit consisted of a single ward with 15 beds. The services were provided by a multi-disciplinary team of physician, nurse, physiotherapist and health care worker. The residing physician would either be a specialist in geriatric medicine and internal medicine or a junior doctor supervised by the geriatrician. Patients were mobilised out of bed and out of the room as soon as possible, and were encouraged to practice and maintain daily self-care activities and to exercise individually indoors and outdoors when possible. They

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were offered individual physiotherapy and group-based exercise. The doctor made a ward round at least twice a week for each patient and other team members participated in the pre-ward round briefing. The multi-disciplinary team met twice weekly, discussed patients systematically and decided further plans for treatment. This included decisions regarding time of discharge within the 3 week maximum and making arrangements for further treatment and care after discharge. Duration: 3 weeks. Concurrent medication/care: not stated. Comments: Hospital at nursing home led by secondary care. (n=200) Intervention 2: Hospital-based care/services. Patients in the control group stayed in hospital and received usual care according to their condition. Some major differences between the intermediate care unit and the hospitals would be presence of physicians at weekends, availability of diagnostic tests, especially radiologic examinations and monitoring equipment like telemetry. In hospitals multi-disciplinary assessment was not applied systematically and patients were not likely to meet a geriatrician. Duration: 3 weeks. Concurrent medication/care: not stated.

Funding Academic or government funding.

RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: HOSPITAL AT HOME LED BY PRIMARY CARE versus HOSPITAL-BASED CARE/SERVICES Protocol outcome 1: Length of hospital stay at during study period - Actual outcome: Length of hospital stay at 1 year; Group 1: mean 10.4 (SD 15.8); n=190, Group 2: mean 10.5 (SD 15.2); n=186; Risk of bias: All domain - High, Selection - Low, Blinding - High, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness Protocol outcome 2: Mortality at during study period - Actual outcome: Mortality at 1 year; Group 1: 42/190, Group 2: 40/186; Risk of bias: All domain - High, Selection - Low, Blinding - High, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcomes not reported by the study Quality of life at during study period; Patient and/or carer satisfaction at during study period; Number of presentations to Emergency Department at during study period; Number of admissions to hospital at After 28 days of first admission; Number of GP presentations at during study period; Readmission up to 30 days; Avoidable adverse events at during study period.

Study Ince 2014154



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Study Ince 2014154

Countries and setting Conducted in Turkey; setting: University School of Medicine and home.


Duration of study Intervention + follow up: follow-up 30 days.




Inclusion criteria Patients with mild non-alcoholic acute pancreatitis (NAAP).

Exclusion criteria Not stated.

Recruitment/selection of patients Not stated.

Age, gender and ethnicity Age - Mean (SD): Home group-54.9 (16.4); hospital group- 54.2 (19.6). Gender (M:F): Define. Ethnicity: not stated.



Interventions (n=42) Intervention 1: Hospital at home - Hospital at home led by primary care. Home monitoring group. After a median of 12 hours patients discharged from hospital and visited on 2nd, 3rd and 5th days by staff nurse. Patients discharged with an IV port and basic instructions for the maintenance of the port. All patients were visited in their homes twice a day by an experienced nurse and all information transferred back to the attending physician. During the home visit, the vital signs, symptoms, and general condition of each patient were recorded and transmitted by the nurse back to the attending physician. Patients given phone numbers of two physicians as emergency contacts. On the 7th, 14th and 30th days, the patients were requested to return for a follow-up visit at which time an assessment of their symptoms, physical examination and lab evaluation was conducted. Duration: 30 days. Concurrent medication/care: not stated (n=42) Intervention 2: Hospital-based care/services. Hospital group – treatment in hospital. Duration: 30 days. Concurrent medication/care: not stated.

Funding No funding.

RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: HOSPITAL AT HOME LED BY PRIMARY CARE versus HOSPITAL-BASED CARE/SERVICES. Protocol outcome 1: Readmission up to 30 days. - Actual outcome: Hospital re-admission at 30 days; Group 1: 1/42, Group 2: 2/42; Risk of bias: All domain - High, Selection - High, Blinding - High, Incomplete outcome

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Study Ince 2014154

data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcomes not reported by the study Quality of life at during study period; Mortality at during study period; Avoidable adverse events at during study period; Patient and/or carer satisfaction at during study period; Number of presentations to Emergency Department at during study period; Number of admissions to hospital at after 28 days of first admission; Number of GP presentations at during study period; Length of hospital stay at during study period.

Study Jakobsen 2015159


Number of studies (number of participants) (n=57).

Countries and setting Conducted in Denmark; Setting: 2 University hospitals and home.


Duration of study Intervention + follow up: follow-up-180 days after discharge.



Subgroup analysis within study Not applicable

Inclusion criteria Patients >45 years of age, with severe or very severe COPD, who had an acute exacerbation of COPD, who were compliant, and who had an expected hospitalisation of more than 2 days.

Exclusion criteria People with need of non-invasive ventilation (NIV) or manual or mechanical ventilation or of intravenous antibiotics, who had a Ph value of <7.35, who had unstable heart disease, malignancy, or poorly regulated diabetes, who were unable to give informed consent, or who had participated in another trial.

Age, gender and ethnicity Age - Mean (SD): <60 years: control- 5 (17.9%); intervention- 5 (17.2) >80 years: control-6 (21.4); intervention-6 (20.7). Gender (M:F): female, n(%): control- 17 (60.7); intervention-18 (62.1). Ethnicity: not stated.

Further population details 1. Frail elderly.

Extra comments Patients admitted with acute exacerbations were treated according to a strict hospital protocol for exacerbations in COPD.


Interventions (n=29) Intervention 1: Hospital at home - Hospital at home led by primary care. Virtual hospital- home based tele-health hospitalisation Participants were transported home within the first 24 hours of hospital admission. Patients were given the following equipment’s – touch screen with webcam, spirometer, thermometer, nebuliser, medicine

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box containing antibiotics, prednisone, sedative, beta 2 agonists and anticholinergics , and oxygen compressor. Patients were ready for daily ward rounds using the touch screen at appointed hours. Unscheduled and acute contacts could always be effectuated 24/7 by the patient pressing the ‘call hospital’ button on the touch screen. Hospital personnel were instructed to treat the telehealth participants exactly the same way as they would treat them had they been present at the hospital except from physical contact which was not possible. Duration: 6 months. Concurrent medication/care: not stated. Comments: Patients in both groups were discharged by the attending doctor if they fulfilled the following five criteria: 1) slept >4 hours without awakening from respiratory symptoms, 2) forced expiratory volume in 1s not decreasing, 3) clinically stable, 4) condition improved during admission, 5) oxygen saturation >90% without supplemental oxygen or with regular oxygen supply if they were long term oxygen users. (n=28) Intervention 2: Hospital-based care/services. The patients allocated to the control group were hospitalised as usual, receiving standard hospital treatment for an exacerbation. Duration: 6 months. Concurrent medication/care: not stated.

Funding No funding.

RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: HOSPITAL AT HOME LED BY PRIMARY CARE versus HOSPITAL-BASED CARE/SERVICES. Protocol outcome 1: Quality of life at during study period. - Actual outcome: Quality of life (EQ-5D summary index) at 30 days after discharge; Risk of bias: All domain - High, Selection - Low, Blinding - High, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness Protocol outcome 2: Mortality at during study period. - Actual outcome: Mortality at 30 days after discharge; Group 1: 0/29, Group 2: 0/28; Risk of bias: All domain - Low, Selection - Low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness - Actual outcome: Mortality at 6 months; Group 1: 3/29, Group 2: 4/28; Risk of bias: All domain - Low, Selection - Low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcomes not reported by the study Avoidable adverse events at during study period; Patient and/or carer satisfaction at during study period; Number of presentations to Emergency Department at during study period; Number of admissions to hospital at After 28 days of first admission; Number of GP presentations at during study period; Readmission up to 30 days; Length of hospital stay at during study period.

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Study Jeppesen 2012160

Study type Systematic review of RCTs – Hospital at home for acute exacerbations of chronic obstructive pulmonary disease (COPD).

Number of studies (number of participants)

8 RCTs (n=870). (7 RCTs included in our review)

Countries and setting Conducted in Australia, Denmark, Italy, Spain and the UK (4 trials).

Duration of study The first search for this review was conducted up to and including August 2003 and the updated search was conducted up to February 2012.

Stratum Admission avoidance.

Subgroup analysis within study

Sys review – pre-specified in protocol.

Inclusion criteria The authors considered only randomised trials (RCTs) where patients presented to the emergency department with an exacerbation of their COPD and were randomised to either home support or hospital admission. They included only trials where patients randomised to home support were discharged from hospital within 72 hours of presenting to the emergency department and after an initial assessment by the hospital medical team.

Exclusion criteria Studies must not have recruited patients for whom treatment at home is not an appropriate option in respiratory guidelines, that is, in the case of patients with an impaired level of consciousness, acute confusion, acute changes on the radiograph or electrocardiogram, arterial pH less than 7.35, concomitant medical conditions or those patients who present at the emergency department for social reasons.

Recruitment/selection of patients

The authors included patients with a diagnosis of COPD with an acute exacerbation presenting to an emergency department for treatment. Studies must not have recruited patients for whom treatment at home is not an appropriate option in respiratory guidelines, that is, in the case of patients with an impaired level of consciousness, acute confusion, acute changes on the radiograph or electrocardiogram, arterial pH less than 7.35, concomitant medical conditions or those patients who present at the emergency department for social reasons.

Age, gender and ethnicity

Overall summary of patient information not provided.

Further population details

Not stated.

Extra comments -

Indirectness of population

No indirectness.

Interventions Patients randomised to home support would be under the care of a specialist respiratory nurse (under guidance of the hospital medical team). All patients randomised to home support would be provided with the treatment as deemed appropriate at the time of initial assessment on presentation to the emergency department. All home support patients would have regular scheduled visits by the nurse as well as additional visits as requested by the patient or deemed appropriate by the nurse or the medical team. All home support patients

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should be visited by the respiratory nurse until discharged from care. Patients randomised to in-hospital care would be treated as usual and at the discretion of the hospital medical team.

Funding Not stated.

Summary of included studies



RCT

Italy

Hospital at home

Team: geriatricians, nurses, physiotherapists, social workers, counsellors

Versus

Control group: routine hospital care.

Adults (n=104) >75 years of age, presenting with acute exacerbation of COPD.

Hospital readmission, mortality at 6 month, quality of life, caregiver satisfaction

Risk of bias (assessed in Cochrane review)

For objective outcomes: Risk of bias: Selection - Low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, other-low

For subjective outcomes: Risk of bias: Selection - low, Blinding - high, Incomplete outcome data - Low, Outcome reporting - Low, other-low

Included in Cochrane:


6 month follow up.

Bowler 200138

Nicholson 2001 215

RCT

Australia

Hospital at Home (in-patient status; home visits by nurses, GP and daily contact between these HP and hospital respiratory team)

Versus

Control: inpatient hospital care

Patients presenting with exacerbation of chronic obstructive pulmonary disease to emergency departments (or respiratory outpatient clinic) of hospital in Brisbane, Australia

Patient satisfaction, carer strain.

Risk of bias (assessed in Cochrane review)For subjective outcomes: Risk of bias: Selection – unclear risk, Blinding - high, Incomplete outcome data - Low, Outcome reporting - high, other-high

In Cochrane Review:


Cotton 200067

RCT


Team: specialist respiratory

Adults (n=81) exacerbation of COPD

Readmission, length of stay, mortality

Risk of bias (assessed in Cochrane



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UK (Scotland) nurses, GP

Versus


review)

For objective outcomes: Risk of bias: Selection - Low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, other-low

For subjective outcomes: Risk of bias: Selection - low, Blinding - high, Incomplete outcome data - Low, Outcome reporting - Low, other-low


Davies 200079

RCT

UK

Hospital at home.

Team: nurse-led but ‘clinical responsibility for the patients remained with the hospital respiratory physician’

Versus



Admissions, quality of life, mortality.


For objective outcomes: Risk of bias: Selection - Low, Blinding - Low, Incomplete outcome data - high, Outcome reporting - Low, other-low

For subjective outcomes: Risk of bias: Selection - low, Blinding - high, Incomplete outcome data - high, Outcome reporting - Low, other-low




3 month follow up

Hernandez 2003141

RCT

Spain


Team: GP-led, respiratory nurse

Versus

Adults (n=222) with exacerbations of chronic COPD

Mortality, ED visits, readmissions, quality of life, satisfaction




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Control group: normal discharge after usual hospital care.

For objective outcomes: Risk of bias: Selection - Low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, other bias-high

For subjective outcomes: Risk of bias: Selection - low, Blinding - high, Incomplete outcome data - Low, Outcome reporting - Low, other bias-high

Ojoo 2002222

RCT

UK

Hospital at home

Team: outreach nurses

Versus


Adults (n=60) >18 years, with an acute exacerbation of COPD

Satisfaction


For subjective outcomes: Risk of bias: Selection – unclear risk, Blinding - high, Incomplete outcome data - Low, Outcome reporting - low, other bias- low




Skwarska 2000277

RCT

UK

Hospital at home


Versus


Adults (n=184) with an acute exacerbation of COPD

Quality of life, satisfaction.


For subjective outcomes: Risk of bias: Selection - low, Blinding - high, Incomplete outcome data - high, Outcome reporting - Low, other-low

Included in Cochrane: Hospital at home early discharge.



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Study Shepperd 2008271

Study type Systematic review of RCTs – Hospital at home admission avoidance.


10 (n=1333). (8 RCTs included in our review).

Countries and setting Conducted in Australia, Italy, New Zealand and the United Kingdom.

Duration of study Databases were searched through to January 2008.




Inclusion criteria Patients aged 18 years and over that were included in admission avoidance hospital at home schemes.

Exclusion criteria Patients with long-term care needs were not included unless they required admission to hospital for an acute episode of care. Evaluations of obstetric, paediatric and mental health hospital at home schemes were excluded from the review since the preliminary literature searches by the authors suggested that separate reviews would be justified for each of these groups.


Randomised controlled trials recruiting patients aged 18 years and over. Studies comparing admission avoidance hospital at home with acute hospital inpatient care. The schemes may admit patients directly from the community, so avoiding physical contact with the hospital, or may admit from the emergency room.

Age, gender and ethnicity Not stated overall.

Further population details Two trials recruited patients with chronic obstructive pulmonary disease (COPD) (Davies 2000; Nicholson 2001), two trials recruited patients recovering from a moderately severe stroke who were clinically stable (Kalra 2000; Ricauda 2004), and three trials recruited patients with an acute medical condition who were mainly elderly (Caplan 1999; Harris 2005; Wilson 1999). As noted above, there was one trial each for patients with cellulitis (Corwin 2005), patients with community acquired pneumonia (Richards 2005).

Extra comments -

Indirectness of population No indirectness

Interventions Hospital at home - Admission avoidance hospital at home schemes compared to acute hospital inpatient care. The schemes may admit patients directly from the community or from the emergency room. Definition used by the authors: hospital at home is a service that can avoid the need for hospital admission by providing active treatment by health care professionals in the patient’s home for a condition that otherwise would require acute hospital in-patient care, and always for a limited time period. In particular, hospital at home has to offer a specific service to patients in their home requiring health care professionals to take an active part in the patients’ care. If hospital at home were not available then the patient would be admitted to an acute hospital ward. Therefore, the following services are excluded from this review:

• services providing long term care;

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• services provided in outpatient settings or post discharge from hospital; and

• self-care by the patient in their home such as self-administration of an intra-venous infusion.

Funding Not stated.



Caplan 200546

Caplan 199947

RCT

Australia

Hospital outreach team providing antibiotics, medications, blood transfusion. Team: included nurse, GP, hospital physician, physiotherapists and occupational therapist.

Versus

Control group: treated in accordance with standard regimens.

Adults (n=100) >65 years of age. Range of conditions including pneumonia, urinary tract infections and cellulitis, endocarditis and osteomyelitis.

Quality of life (Barthel), patients and carer satisfaction, adverse events and mortality.


Risk of bias: Selection – low (no further details for other domains)



3 month follow up.

Corwin 200566

RCT

New Zealand

Hospital at home

Team: GP or community GP and community care nurses

Versus

Control group: hospital administration of antibiotics.

Adults (n=200) >16 years of age, with clinical signs of cellulitis or failure of oral antibiotics

Adverse events, length of stay, satisfaction





Davies 200079

RCT

UK

Hospital at home.

Team: nurse-led but ‘clinical responsibility for the patients remained with the hospital respiratory physician’

Versus



Admissions, quality of life, mortality.


Risk of bias: Selection – unclear risk (no further details for other domains)




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3 month follow up

Harris 2005138

RCT

New Zealand

Home from hospital

Team: nurse-led but ‘clinical responsibility was held by dedicated HAH registrar, consultant geriatrician and in some cases the GP’

Versus

Adults (n=285) with a mean age of 81 years presenting at ED or admitted to hospital for a broad range of diagnoses: fractures (28%); miscellaneous medical problems (18%); respiratory problems (16%); stroke and neurological diagnoses (14%); falls and injuries

(11%); cardiac diagnoses (8%); and rehabilitation and other problems (5%)

Location: New Zealand






Kalra 2000164

RCT

UK

Hospital outreach admission avoidance MDT with joint care from community services. Three arm trial:

Stroke unit care (n=148)

Versus

Stroke team (n=150)

Versus

Home care (n=149)

Adults (n=457) recovering from a moderate to severe stroke

Mortality, Readmission, length of stay, Ranking level of independence, Barthel





Nicholson 2001215

RCT

Australia

Hospital at home (discharge from Emergency Department)

Patients retained in patient status and received clinical supervision from hospital specialist,

and hospital had legal and financial responsibility; also

Patients with chronic obstructive pulmonary disease

Inclusion criteria:

age > 45 years, COPD, current or ex smoker, FEV1 < 60% predicted, admission requested

by GP or OPD clinic staff or ED

Cost to the health service



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received care from GP, community nursing and domiciliary care. Hospital medical staff provided 24 hour telephone support

staff, telephone at home

treatment = 13

control = 12

Ricauda 2004240

RCT

Italy

Home treatment (from a geriatric home hospitalisation service)

Team: geriatricians, nurses, dieticians, physiotherapists, psychologists and social workers dedicated to the home management of stroke.

Versus

General medical ward.

Adults (n=120) elderly patients, with a mean age of 82 years; admitted to the emergency department with first acute ischemic stroke.

Quality of life, mortality, avoidable adverse events (respiratory and urinary tract infections)





Richards 2005242

RCT

New Zealand

Hospital at home

Team: GP and primary care nurses

Versus

Control group: hospital management

Adults (n=55) with mild to moderately severe pneumonia

Length of stay (days to discharge), satisfaction.





Wilson 1999312

Wilson 2002314

Wilson 2003313

RCT

UK

Hospital at home

Team: nurse-led, physiotherapist, occupational therapists, health workers. GPs retain responsibility.

Versus

Control group: hospital care.

Adults (n =199) with an acute condition.

Mortality, readmission, length of stay, satisfaction.





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Study type Systematic review of RCTs – Hospital at home early discharge.


26 (n=3967). (6/26 studies included in our review)

Countries and setting Conducted in Australia, Canada, New Zealand, Norway, Sweden, Thailand, and the UK (the majority of trials).

Duration of study Databases were searched through to January/February 2008.




Inclusion criteria The review includes evaluations of early discharge hospital at home schemes that include patients aged 18 years and over. Patients were either recovering from a stroke, following elective surgery, or were older people with a mix of conditions.

Exclusion criteria Patients with long-term care needs were not included unless they required admission to hospital for an acute episode of care. Evaluations of obstetric, paediatric and mental health hospital at home schemes were excluded from the review since the authors’ preliminary literature searches suggested that separate reviews would be justified for each of these groups due to the different types of patient group and volume of literature. The following services were excluded from this review: services providing long term care, services provided in out-patient settings or post discharge from hospital, and self-care by the patient in their home such as self-administration of an intravenous infusion.


The review includes evaluations of early discharge hospital at home schemes that include patients aged 18 years and over. Patients were either recovering from a stroke, following elective surgery, or were older people with a mix of conditions.

Age, gender and ethnicity Not stated overall.


Extra comments -

Indirectness of population No indirectness – we excluded the papers with patients recovering from elective surgery for our analysis.

Interventions Studies comparing early discharge hospital at home with acute hospital in-patient care. The authors used the following definition to determine if studies should be included in the review: hospital at home is a service that provides active treatment by health care professionals in the patient’s home for a condition that otherwise would require acute hospital in-patient care, and always for a limited time period. In particular, hospital at home has to offer a specific service to patients in their home requiring health care professionals to take an active part in the patients’ care. If hospital at home were not available then the patient would not be discharged early from hospital and would remain on an acute hospital ward. Therefore, the following services were excluded from this review: services providing long term care, services provided in out-patient settings or post discharge from hospital, and self-care by the patient in their home such as self-administration of an intravenous infusion.

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Funding Not stated.



Cotton 200067

RCT

UK


Team: specialist respiratory nurses, GP

Versus


Adults (n=81) exacerbation of COPD

Readmission, length of stay, mortality






Donald 199589

RCT

UK

Hospital at home

Team: full-time nurse, manager/coordinator, physiotherapists and occupational therapists. Overall responsibility for the patient while under the care of HAH remained with the consultant, although the GP provided routine and emergency medical care

Versus

Control group: conventional discharge.

Adults (n=60) with a mean age of 82 years, who had been admitted acutely under the care of the elderly care physicians.

Readmission, mortality, length of hospital stay.



In Cochrane Review:


Harris 2005138

RCT

New Zealand

Home from hospital

Team: nurse-led but ‘clinical responsibility was held by dedicated HAH registrar, consultant geriatrician and in some cases the GP’

Versus

Adults (n=285) with a mean age of 81 years presenting at ED or admitted to hospital for a broad range of diagnoses: fractures (28%); miscellaneous medical problems (18%); respiratory problems (16%); stroke and neurological

Mortality, Readmission, Quality of life, Satisfaction, Length of stay






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diagnoses (14%); falls and injuries

(11%); cardiac diagnoses (8%); and rehabilitation and other problems (5%)

Location: New Zealand

Ojoo 2002222

RCT

UK

Hospital at home

Team: outreach nurses

Versus


Adults (n= 60) >18 years, with an acute exacerbation of COPD

Satisfaction






Shepperd 1998265

Shepperd 1998268

RCT

UK

Hospital at home

Team: nurse-led, physiotherapist, occupational therapist, pathology, SALT. GPs held responsibility.

Versus

Control group: inpatient hospital care.

Adults (n=532) recovering from surgery mainly but elderly and COPD patients also (table 6&7); outcomes for medical elderly patients reported only

Quality of life, carer satisfaction, readmission, mortality.




Skwarska 2000277

RCT

UK

Hospital at home


Versus


Adults (n=184) with an acute exacerbation of COPD

Quality of life, satisfaction.






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Hospital at home (Primary Care)

Study COURTNEY 200968


Number of participants Intervention group=64.

Control group=64 (n=128).

Countries and setting Tertiary metropolitan hospital in Australia.

Duration of study Recruitment August 2004 – December 2006. Follow up for 24 weeks.

Stratum Overall.


Quality of Life measure according to the four major admission diagnoses (cardiac, respiratory, gastrointestinal and falls).

Inclusion criteria Inclusion criteria were chosen based on previously published research identifying risk factors for readmission.

65 years or older and admitted with a medical condition.

At least 1 risk factor for readmission (aged >75, multiple admissions in previous 6 months, multiple comorbidities, lived alone, lacked social support, poor self-rated health, moderate to severe functional impairment and history of depression).

Exclusion criteria Patients’ ability to participate in the planned intervention (for example, patients who were unable to walk independently or suffered a cognitive deficit would not be able to safely manage the intervention exercise programme).


A sample of 128 participants was recruited within 72 hours of admission to medical wards at a tertiary hospital in Brisbane, Australia. An information package on the study was provided and explained to potential participants, and signed consent was obtained from all participants. Baseline data were collected before randomisation and were thus blinded. After collection of baseline data, the research nurse at the clinical site contacted the project coordinator, who was blinded to baseline data and randomly allocated participants using a computerised randomisation program to the control or intervention group.

Age, gender and ethnicity Age

Mean: 78.8

Gender

(% of F): 62.3% (76/122)

Ethnicity: not stated.


Extra comments -


Interventions (n=64)Intervention 1: Hospital at home-In addition to usual care, they received an intervention following the ‘Older Hospitalised Patients’

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Discharge Planning and In-home Follow-up Protocol (OHP-DP)’, developed by the authors. The protocol commenced within 72 hours of admission and continued within 72 hours of admission and continued throughout hospitalisation, after transfer to home and in home for 6 months. The intervention was modified to the population of older patients who are at known risk of readmission yet still relatively healthy and potentially able to live independently, because it was felt that this group would particularly benefits from a relatively low resource intensive preventative intervention.

Within 72 hours of admission, a registered nurse and physiotherapist undertook a comprehensive patient and developed a goal-directed, individualised care plan in consultation with the patient, health professionals, family and caregivers. The care plan included exercise intervention, nursing intervention while participant in the hospital, intervention after discharge. The latter included a nurse home visit within 48 hours of discharge to assess access availability of support, address transitional concerns, provide advice and support and ensure that the exercise program could be safely undertaken at home. Extra home visits were provided if required. Weekly follow-up telephone calls were provided for 4 weeks, followed by monthly follow up for a further 5 months. The nurse was also available for contact between 9am and 5pm weekdays.

(n=64)Intervention 2: Hospital based care/services: Participants in the control received the routine care, discharge planning and rehabilitation advice normally provided. If in-home follow-up was necessary, it was organised in the routine manner (for example, referral to community health services).

Funding Australian Research Council Discovery Project Grant.

RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: HOSPITAL AT HOME (PRIMARY CARE) versus INPATIENT HOSPITAL CARE.

Protocol outcome 1: Length of stay. - Actual outcome: Length of stay; Group 1: Mean (SD): 4.6 (+/-2.7); Group 2: Mean (SD): 4.7 (+/-3.3); Risk of bias: All domain - low, Selection - low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

- Actual outcome: Emergency hospital readmissions; Group 1: 22.0% (21 readmissions); Group 2: 46.7% (49 readmissions); Risk of bias: All domain - low, Selection - low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 3: GP presentations. - Actual outcome: Emergency GP visits; Group 1: 25.0% (13 emergency GP visits); Group 2: 67.3% (86 emergency GP visits); Risk of bias: All domain - low, Selection - low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 4: Quality of Life. - Actual outcome: Health-related Quality of Life: Physical Component and Mental Component summary score; Group 1: Physical: Mean (SD): 43.8 (+/-9.4), Mental: Mean (SD): 59.4 (+/-5.1); Group 1: Physical: Mean (SD): 26.0 (+/-9.9), Mental: Mean (SD): 48.3 (+/-7.7); Risk of bias: All domain - low, Selection - low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

.

Protocol outcomes not Mortality, avoidable adverse events, patient and/or carer satisfaction, length of stay, number of avoidable admissions.

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reported by the study

Study KWOK 2008173



Control group=56 (n=105).

Countries and setting Prince of Wales Hospital, a major teaching hospital in Hong Kong.

Duration of study Recruitment September 1999 – February 2001. Follow up for 6 months.



No.

Inclusion criteria > 60 years of age.

Residing within the region.

At least one hospital admission for chronic heart failure in the 12 months prior to the index admission.

Exclusion criteria Communication problems but without caregivers.

Residing in a nursing home.

Terminal diseases with a life expectancy of less than 6 months.


Eligible subjects were identified and recruited by a research nurse on the day or the day before hospital discharge. After obtaining written consent from the subjects, the research nurse recorded demographic data, functional status, cognitive function, psychological state and a general health questionnaire. The ward nurses then phoned a second research assistant who assigned trial grouping according to a random number table. The group assignment was made known to patients.

One intervention and two control group subjects dropped out because of moving out of Hong Kong and the development of symptomatic cancer.

Age, gender and ethnicity Age.

Mean (SD); Intervention: 79.5 years (+/-6.6). Control: 76.8 years (+/-7.0).

Gender.

(% of M): Intervention: 45.0% (22/49). Control: 45.0% (25/56).


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Study KWOK 2008173

Further population details The intervention group subjects were more likely to be recipients of ‘comprehensive social security allowance’ and had greater economical handicap.

Extra comments


Interventions (n=49) Intervention 1: Hospital at home- The subjects were visited by a designated community nurse before they were discharged from the hospital. The objectives were to provide health counselling, such as drug compliance, dietary advice and to encourage subjects to contact the community nurse via a telephone hotline during office hours when they developed symptoms. The community nurse carried a pager and a mobile phone. The trained clerk, who answered the hotline, relayed the message from the subjects to the community nurse via the pager.

The subjects were then visited by the community nurse at home within seven days of discharge. During the home visits, the community nurse checked vital signs and signs for poor control of CHF –ankle swelling, dyspnoea and basal crepitation on auscultation. Medications were checked and compliance encouraged. Avoidance of salty and high fat foods and regular physical exercise were promoted. Home care and day care services were arranged if social support was found to be insufficient.

The community nurse thereafter performed weekly home visits for another month and monthly thereafter. The community nurse liaised closely with either a geriatrician or a cardiologist in their respective hospitals. After liaison, the community nurse could alter medication regime, arrange urgent hospital outpatient appointments and clinical admission. When subjects were readmitted, the community nurse visited the patient in hospital and provided background information to attending doctors. Subjects who refused further home visits were monitored by the community nurse by telephone.

n=56) Intervention 2: The control subjects received usual medical and social care, except that they were followed up in the hospital outpatient clinics by the same group of designated geriatricians or cardiologists.

Funding Health Services Research Committee/Health Care & Promotion Fund of Hong Kong.


Protocol outcome 1: Readmission. - Actual outcome: Readmission rates; Group 1: 46.0% (21 readmissions); Group 2: 57.0% (49 readmissions);

Risk of bias: All domain - High, Selection - High, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 2: Mortality. - Actual outcome: Death; Group 1: 4/49; Group 2: 8/56; Risk of bias: All domain - High, Selection - High, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcomes not reported by the study

Avoidable adverse events, quality of life, patients and/or carer satisfaction, length of stay, number of presentations to ED, number of avoidable admissions, reduced GP presentations.

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Study RICH 1993241



Control group=35 n=90.

Countries and setting Jewish Hospital at Washington University; secondary and tertiary care university teaching hospital.

Duration of study Recruitment April 1988 – March 1989. Follow up for 3 months.

Stratum Early discharge

Readmission risk categories low (0 risk factors n=52), intermediate (1 risk factor, n=123) or high (≥ 2 risk factors, n=65) based on the presence of four independent risk factors for readmission defined in a prior study at the same institution: four or more prior hospitalisations within the preceding five-year interval, previous history of CHF, hypercholesterolemia and right bundle branch block on the admitting ECG.


Moderate-risk and high-risk subgroups.

Inclusion criteria > 70 years of age.

Admitted to medical ward between April 1988 and March 1989

Definite diagnosis of CHF (presence of definite radiographic evidence of pulmonary congestion) or by the presence of typical historical and physical findings of the CHF in conjunction with symptomatic improvement following dieresis.

Exclusion criteria Low risk for readmission, as these patients would be unlikely to benefit significantly from a program designed to reduce readmission frequency.

Residence outside the catchment area.

Planned discharge to a nursing home or other chronic care facility.

Non-cardiac illness likely to result in non-preventable readmission (for example, terminal malignancy).

Server mental incapacity or psychiatric disturbance.

Patient or physician refusal.

Logical and discretionary reasons.


98 patients agreed to participate. After signing appropriate informed consent documents, the subjects were stratified according to risk category and randomly assigned on a 2:1 basis to receive either the study intervention or conventional medical care as determined by the patients’ usual physician.

21 patients (8%) died during the initial hospitalisation and were excluded from further analysis.


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Study RICH 1993241

Mean (SD); Intervention: 80 years (+/-6.3). Control: 77.3 years (+/-6.1).

Gender

(% of M): Intervention: 39.7% (25/63). Control: 42.9% (15/35).

Ethnicity (White).

Intervention: 46.0% (29/63). Control: 57.1% (20/35).

Further population details

Extra comments


Interventions (n=63) Intervention 1: Hospital at home- Consisted of four components: intensive education about CHF and its treatments, a detailed analysis of medications with specific recommendations designed to improve compliance and reduce adverse effects, early discharge planning and enhanced follow-up through home care and telephone contacts.

At the time of discharge, a discharge summary form was completed by the study nurse detailing medications, dietary and activity restrictions and any anticipated problem areas identified by the social worker, hospital home care representative or study personnel. This form was transmitted to a nurse working with the Jewish Hospital Home Care Division, who then visited the patient at home within 48 hours (in most cases within 24 hours) of hospital discharge. In addition to surveying the home environment and identifying any additional problem areas, the home care nurse again reinforced the teaching materials, reviewed medications, diet and activity guidelines, assisted with initiating the daily weight chart and performed a general physical assessment and cardiovascular examination. The patients were seen three times in the first week, during which time the above functions were repeated and they were subsequently seen at regular intervals in accordance with federal home-care guidelines. In addition, the study burse contacted all patients by telephone to assess their progress, answer any questions and keep communication line open. All patients were encouraged to contact study personal or their personal physicians anytime new problems, symptoms or questions occurred.

(n=35) Intervention 2: Hospital based care/services-The patients randomised to standard care received all conventional treatments as requested by the patients attending physician. Such measures could include social service evaluation, dietary and medication teaching, home care and all other available hospital services. However, because these patients were not seen regularly by the study nurse and did not receive the study educational materials or the formal medication analysis, the intensity of teaching was lower for the usual-care group.

Funding Community Research Grant-in-Aid from the American Heart Association.


Protocol outcome 1: Readmission. - Actual outcome: Readmission rates; Group 1: 33.3% (21/63 readmissions); Group 2: 45.7% (16/35 readmissions); Risk of bias: All domain - High, Selection - High, Blinding - High, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness Protocol outcome 2: Length of stay.

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Study RICH 1993241

- Actual outcome: Total hospital days; Group 1: Mean (SEM): 4.3 (+/-1.1); Group 2: Mean (SEM): 5.7 (+/-2.0); Risk of bias: All domain - High, Selection - High, Blinding - High, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness


Mortality, avoidable adverse events, quality of life, patient and/or carer satisfaction, number of presentations to ED, number of avoidable admissions, reduced GP presentations.

Study STEWART 1998281 STEWART 1999280


Number of participants Home based intervention=49.

Usual care=48 (n=97)

Countries and setting Cardiology Unit of the Queen Elizabeth Hospital/University of Adelaide, Woodville, South Australia.

Duration of study 6 month follow up.

Stratum Overall.


n/a.

Inclusion criteria Presence of CHF (defined on the basis of a formal demonstration, impaired systolic function and persistent functional impairment indicative of New York Heart Association class 2, 3 or 4 statuses.

Acute ischemia or infarction with previously documented CHF were included.

Being discharged home and requiring continuous pharmacotherapeutic intervention for a chronic condition.

Patients with CHF who were determined to be at high risk for unplanned readmission were identified on the basis of 1 or more unplanned admissions for acute heart failure before study entry.

Exclusion criteria Acute MI or unstable angina pectoris.

Presence of terminal malignancy requiring palliative care.

Home address outside catchment area.


Not stated.


Years (SD); Intervention: 76 years (+/-11). Control: 74 years (+/-10).

Gender.

M:F; Intervention: 22:27. Control: 25:23.

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Ethnicity (Non-English speaking background).

Intervention: 10/49. Control: 9/48.


Extra comments -


Interventions (n=49) Intervention 1: Hospital at home- Before discharge, patients assigned to an HBI (n=49) were visited by the study nurse (S.P.) and counselled in relation to complying with the treatment regimen and reporting any sign of clinical deterioration or acute worsening of their heart failure. One week after discharge, these patients were visited at home by the study nurse and pharmacist. On arrival, the study pharmacist performed an assessment of the patient’s knowledge of the prescribed medications (via questionnaire) and the extent of compliance (via pill count). Patients who demonstrated poor medication knowledge (<75% composite knowledge score of dosage, intended effect, potential adverse effects, and special instructions) or malcompliance (≥15% deviation from prescribed dosage at discharge) received a combination of the following: (1) remedial counselling, (2) initiation of a daily reminder routine to enhance timely administration of medications, (3) introduction of a weekly medication container enabling pre-distribution of dosages, (4) incremental monitoring by caregivers, (5) provision of a medication information and reminder card, and (6) referral to a community pharmacist for more regular review thereafter.

Patients were further evaluated by the study nurse to detect any clinical deterioration or adverse effects of prescribed medication since discharge; those requiring medical review were immediately referred to their primary care physician. After the home visit, all patients’ primary care physicians were contacted by the study nurse to inform them of the home visit and to discuss the need (if any) for further remedial action or more intensive follow-up thereafter.

(n=48) Intervention 2: Hospital based care/services- Patients assigned to the UC group (n=48) received the pre-existing levels of post discharge care: all patients in the UC group had appointments to be reviewed by their primary care physician or cardiologist (in the hospital’s outpatient department) within 2 weeks of discharge. Furthermore, 13 patients (27%) were receiving regular home support (for example, domiciliary care or community nurse visits) after discharge.

Funding Commonwealth Department of Health and Family Services, Canberra, Australia, through the Pharmaceutical Education Program.


Protocol outcome 1: Readmission. - Actual outcome: Unplanned Readmission rates; Group 1: 24/49 readmissions; Group 2: 31/48 readmissions. Risk of bias : Selection - Low, Outcome reporting - high, other-unclear risk

Protocol outcome 2: Mortality. - Actual outcome: Out of hospital deaths; Group 1: 6/49; Group 2: 12/48. Risk of bias : Selection - Low, Outcome reporting - high, other-unclear risk

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Avoidable adverse events, quality of life, patient and/or carer satisfaction. Length of stay, number of presentations of ED, number of avoidable admissions, reduced GP presentations.

Hospital at Home (Secondary Care)

Study MENDOZA 2009202

Study type RCT; prospective, randomised study


1 (n=80); Randomised into 2 groups (1:1); 9 patients withdrew; analysis done on n=71; Hospital at Home (n=37), Inpatient Hospital Care (n=34)

Countries and setting Txagorritxu University Hospital, Vitoria-Gasteiz, Spain, with a catchment area of 250’000 people and a HaH unit staffed by 6 physicians and 8 nurses

Duration of study Between May 2006 and March 2007

Stratum Admission avoidance


n/a

Inclusion criteria Aged ≥65 years; with diagnosis and prognosis evaluation of heart failure (HF) since at least 12 months prior to the study; New York Heart Association (NYHA) functional class II or III before coming to ED due to exacerbation

Exclusion criteria Admitted in the preceding 2 months for deterioration of HF or acute coronary syndrome; presence of severe symptoms such as sudden worsening of HF; poor prognosis factors (haemodynamic instability, severe arrhythmia, baseline creatinine above 2.5 mg/dL); no response to treatment in the ED; active cancer, severe dementia, or any other disease at an advanced stage indicating life expectancy of less than 6 months; acute psychiatric diseases, active alcoholism; active pulmonary tuberculosis; those living in a psycho-geriatric institution; no guarantee of all-day supervision; absence of a telephone at home or living more than 10km from the hospital


All patients sought care at the ED on their own initiative or were referred by GP. When ED doctors diagnosed decompensation of CHF and identified patient as potential candidate for the study based on eligibility criteria, the doctor responsible for recruitment to the study was called. Once patient assigned consent form, they were randomly allocated (1:1) to one of the intervention groups.

Age, gender and ethnicity Hospital at Home (n=37)= Age – Mean (SD): 78.1 years (6.2). Gender (M/F): 1/1. Ethnicity: no information given

Inpatient Hospital Care (n=34)= Age – Mean (SD): 79.9 years (6.3). Gender (M/F): 2/1. Ethnicity: no information given

Further population details There are differences in group characteristics although not statistically significant:

For example, patients in Inpatient Hospital Care group slightly older, more males (p=0.06), less admissions in previous year for HF, lower functional status (p=0.06; Barthel index).

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Extra comments Although they recorded data at months 1, 3, 6 and 12, the authors only report outcome data at 1 year follow-up.


Interventions (n=37) Intervention 1: Hospital at Home- HaH unit staffed by 6 physicians and 8 nurses

Patients were explained HaH unit while they were still in ED, given an info sheet and contact numbers. Within 12 – 24 hours of ED visit they received visits to their homes from an internal medicine specialist and a nurse, who were staff members of the HaH unit. In case of deterioration occurring outside working hours (daily 8am to 9pm), patients and family were instructed to call 112, emergency services, explaining that they were patients under the supervision of the HaH unit. Apart from nursing and clinical evaluation, samples were taken for laboratory tests and ECGs performed in patient’s home when necessary. X-ray and echocardiography at hospital was equally accessible for HaH patients as for inpatients. Daily visits by specialist nurse. Physician visited daily or every other day depending on their clinical condition. Treatment within HaH finished with referral to primary care after recovery or, in the case of deterioration or no response to treatment, with transfer to the cardiology ward.

(n=34) Intervention 2: Inpatient Hospital Care

Patients were admitted to the hospital, cardiology ward and were managed by the usual staff of cardiology specialists and nurses, in accordance with guideline recommendations.

Concurrent medication/care: both received usual care

Follow-up: After initial admission (intervention), patients were followed up by their primary care physician, who was not aware of the study. A physician or nurse from the study team contacted each patient at months 1, 3, 6 and 12 to record events such as death, new admissions, or visits to ED, the cardiologist, or GP. Blood tests, re-evaluation of functional status and health-related QoL were performed at month 12.

Funding This study was financed with a grant from the Caja Vital Kutxa (‘a Spanish Savings Bank, a socially-conscious financial institution that leads the financial sector in its 116 area of influence’).

All results at 12 months follow-up as no other data presented

RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: HOSPITAL AT HOME versus INPATIENT HOSPITAL CARE Protocol outcome 1: Mortality - Actual outcome: Death; Group 1: n=2/37; Group 2: n=3/34; p=0.67; Risk of bias: All domain - High, Selection - High, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 2: Readmission - Actual outcome: Readmission for heart failure at 1 year; Group 1: n=15/37, Group 2: n=17/34; p=0.42; Risk of bias: All domain - High, Selection - High, Blinding - High, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

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Protocol outcome 3: length of stay - Actual outcome: average length of stay: days (SD); Group 1: 10.9 (5.9), Group 2: 7.9 (3.0); p=0.01; Risk of bias: All domain - High, Selection - High, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness Protocol outcome 4: Quality of Life (physical) - Actual outcome: Quality of Life (physical component of SF36); Group 1: 3.6 (-0.5; 7.7); Group 2: 2.2 (-1.9; 6.4); p=0.47; Risk of bias: All domain - High, Selection - High, Blinding - High, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness Protocol outcome 5: Quality of Life (mental) - Actual outcome: Quality of Life (mental component of SF36); Group 1: 4.0 (-0.9; 8.9), Group 2: 2.8 (-2.4; 8.0); p=0.38; Risk of bias: All domain - High, Selection - High, Blinding - High, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness Protocol outcome 6: Functional status (difference from baseline) - Actual outcome: Variation in Barthel Index (higher values=more independent); Group 1: 4.0 (-0.9; 8.9), Group 2: 4.7 (-2.2; 11.5); p=0.21; Risk of bias: All domain - High, Selection - High, Blinding - High, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness


Avoidable adverse events, patient and/or carer satisfaction, number of presentations to ED, number of unnecessary admissions, reduced GP presentations

Study PATEL 2008229

Study type RCT; open, randomised, controlled pilot study


1 (n=31); Randomised into 2 groups; Hospital at Home (n=13), Conventional Care (n=18)

Countries and setting Sahlgrenska University Hospital/Oestra, a hospital serving 250’000 inhabitants in Goeteborg, Sweden

Duration of study Between April 2004 and May 2006

Stratum Early discharge


n/a

Inclusion criteria Prior diagnosis of chronic heart failure (CHF) according to the European Society of Cardiology guidelines, assessed as being in need of hospital care by their consulting physician and complying with all of the inclusion criteria:.

Earlier diagnosed with (CHF) with diastolic or systolic left ventricular dysfunction; deterioration of HF 3 days with symptoms of increasing dyspnoea, orthopnoea, weight gain ≥ 2kg, debuting peripheral oedema or abdominal swelling; clinical signs, for example, extended

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Study PATEL 2008229

jugular vein, leg oedema, tachypnoea, pulmonary rales, ascites and third heart sound; at least one symptom and one sign should be present; New York Heart Association (NYHA) class II-IV

Exclusion criteria Unwillingness to participate; worsening of CHF <3 days; newly onset HF; pulmonary or pre-pulmonary oedema; need for monitoring of arrhythmia; other morbidities indicating need for hospitalisation; living at an institution; inability to follow instructions; S-Haemoglobin < 100 g/L or a decrease of S-haemoglobin > 20 g/L; S-Creatinine > 250 µmol/L; S-Potassium >5.5 mmol/L or <3.4 mmol/L; S-Troponin T>0.05 µg/L; Creatine kinase-MB>5 µg/L; ASAT and ALAT >three times above the normal value; Systolic blood pressure <95 mm Hg; heart rate <45 or >110 beats/min


Patients seeking care for deterioration of CHF were identified within 24 hr after admission from 3 medical facilities: an ED, a heart failure (HF) outpatient clinic and a medical ward. After one year the protocol was amended with an extension of time to 48 hr for study inclusion.

After consent was obtained routine blood tests were performed, complete history taken and examination done by cardiologist, and then patients were randomised to one of the 2 groups.

Age, gender and ethnicity Hospital at Home (n=13)= Age – Mean (SD): 77 years (10). Gender (M/F): 1/1. Ethnicity: no information given

Conventional Care (n=18)= Age – Mean (SD): 78 years (8). Gender (M/F): 4/1. Ethnicity: no information given

Further population details The conventional care group included a larger number of male, more educated patients as well as a higher prevalence of diabetes (p<0.05).

Extra comments Three of the 18 patients in the conventional care group withdrew their consent during the study period (2 because of fatigue, 1 did not give a reason). Sample size quite small; considerably smaller than their sample size calculation suggested (77 per group).

Paper sets out to measure QoL but then does not report it, just QALY’s. Study records follow-ups at 1, 4, 8 and 12 months, but only presents data relevant to clinical review at 12 months follow-up. Paper is not clear whether they are Means (SD) or Medians (SE).


Interventions (n=13) Intervention 1: Hospital at home

Hospital at Home (paper calls it Home Care group): patients were initially treated in ED or in the ward for up to 48 hrs and subsequently sent home. All patients were followed up the day after returning home by a specialist nurse from the HF clinic. Patients were visited daily or every other day by the specialist nurse for the next 5-7 days as determined by the patients’ health status. Home visits were terminated when a patient: was symptomatically stable or improving; had stable or falling weight; had no signs of pulmonary rales and had no oedema above the ankle. Specialist nurse could be phoned during office hours; nurses at intensive cardiac care unit could be phoned after office hours. Cardiologist was always available for telephone consultation. After termination of home visits, patients were referred to the HF clinic for drug up-titration if necessary. After each home visit, the nurse and study physician had a short consultation to discuss the patient’s condition.

(n=18) Intervention 2: Conventional Care -patients treated in accordance with hospital treatment guidelines. All data were collected in the same way as in the HC group.

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Study PATEL 2008229


Funding Support from Swedish Research Council and other academic and government bodies.


RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: HOSPITAL AT HOME versus CONVENTIONAL CARE Protocol outcome 1: Mortality - Actual outcome: Death; Group 1: n=2/13; Group 2: n=2/18;

Risk of bias: All domain - high, Selection - high, Blinding - high, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 2: length of stay - Actual outcome: average length of stay of hospitalisation: mean number of days (SD); Group 1: 5.6 (9.4); Group 2: 4.5 (6.2);



Avoidable adverse events, patient and/or carer satisfaction, number of unnecessary admissions, presentation to ED (data does not make sense – removed from analysis), re-admission (data does not make sense – removed from analysis), reduced GP presentations; quality of life

Study TIBALDI 2009296

Study type RCT; prospective, single-blind, randomised controlled trial


1 (n=101); Randomised into 2 groups (1:1); Hospital at Home (n=48), General Medical Ward (n=53); followed-up to 6 months: Hospital at Home (n=39), General Medical Ward (n=43)

Countries and setting San Giovanni Battista Hospital of Torino, Italy (large, urban university teaching and tertiary care hospital)

Duration of study 1st April 2004 to 31st April 2005

Stratum admission avoidance


n/a

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Inclusion criteria Aged ≥75 years with pre-existing diagnosis of chronic heart failure (CHF- stage C according to the American Heart Association classification) and a persistent functional impairment indicative of New York Heart Association (NYHA) class III or IV status were considered eligible for the study when admitted to the ED of the hospital for acute decompensation of their chronic condition and assessed as being in need of hospital care. Additional inclusion criteria: appropriate care supervision at home, telephone connection, living in the hospital-at-home catchment area, informed consent, at least 1 previous admission for acute CHF, and need for intravenous drug infusion

Exclusion criteria New-onset heart failure; absence of family and social support; need for mechanical ventilation, haemodialysis, or intensive monitoring; severe dementia (Mini Mental Examination score <14); terminal malignant neoplasm; severe renal impairment (estimated glomerular filtration rate <20 mL/min); hepatic failure (Child-Pugh classes B and C); serum haemoglobin levels less than 9 g/dL (to convert to grams per litre, multiply by 10); and planned cardiac surgery (for example, valve replacement).


In the ED all potentially eligible patients with an acute decompensation of CHF underwent baseline standard clinical evaluation, routine blood tests, chest radiography etc. Study participants were enrolled within 12 to 24 hours of ED admission by research assistants who screened patients for eligibility and obtained informed consent. The project manager then randomly assigned patients to one of the two groups.

Age, gender and ethnicity Hospital at Home (n=48)= Age – Mean (SD): 82.2 years (5.2). Gender (M/F): 1/1. Ethnicity: no information given

General Medical Ward (n=53)= Age – Mean (SD): 80.1 years (4.9). Gender (M/F): 1/1. Ethnicity: no information given

Further population details At baseline 2 groups were similar in all sociodemographic, health and clinical characteristics apart from age: patients in HaH group slightly older (p=0.04).

Extra comments Sample analysed on intention-to-treat basis. The population sample was very old, comorbid and acutely ill. The number of deaths (7 in HaH and 8 in hospital group) and patients lost to follow-up (2 in each group) was very similar for both groups.


Interventions (n=48) Intervention 1: Hospital at Home

Hospital at Home (paper calls it Geriatric Hospital at Home service): provides substitutive HaH care in a clinical unit model and has been in operation for more than 20 years. The MDT is equipped with 7 cars and consists of 4 geriatricians, 13 nurses, 3 physios, 1 social worker, and 1 counsellor. The main feature is that physicians and nurses work together as a team, with daily meetings to discuss the needs of each patient and to organise individualised medical care plans. 7 days a week and on average for 25 patients per day and 450 patients per year. Close collaboration between HaH team and ED department. HaH patients are considered hospital patients, and all services are provided by the hospital, which retains legal and financial responsibility for care. In the ED all necessary diagnostic tests are provided and then the patient moves home by ambulance. In the first days after admission to HaH each patient was visited at home on a daily basis by physicians and nurses. Thereafter at intervals of 2 to 3 days or less, as required by the clinical condition of the patient.

(n=53) Intervention 2: General Medical Ward

Routine hospital care. Protocols for prevention of nosocomial infections, bed sores, and immobilisation are routinely adopted for frail

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elderly inpatients.


Study reports follow-up at 6 months.

Funding Not mentioned. But author affiliations are with the Department of Medicine at the University of Torino, Italy


RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: HOSPITAL AT HOME versus GENERAL MEDICAL WARD Protocol outcome 1: Mortality - Actual outcome: Death; Group 1: n=7/48; Group 2: n=8/53; Risk of bias: All domain - low, Selection - low, Blinding - low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 2: Admission - Actual outcome: Admission to hospital; Group 1: n=8/48, Group 2: n=18/53; Risk of bias: All domain - low, Selection - low, Blinding - low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness Protocol outcome 3: length of stay - Actual outcome: average length of stay in ED: mean hours (SD; range); Group 1: 14.6 (3.4; 3-24 hrs), Group 2: 16.3 (3.0; 5-24 hrs); Risk of bias: All domain - low, Selection - low, Blinding - low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectnessProtocol outcome 4: length of stay - Actual outcome: average length of stay of first additional hospital admission: mean (SD); Group 1: 22.1 (9.5); Group 2: 25.3 (12.2); Risk of bias: All domain - low, Selection - low, Blinding - low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness Protocol outcome 5: length of stay - Actual outcome: overall length of treatment: mean days (SD); Group 1: 20.7 (6.9); Group 2:11.6 (10.7); p=0.001; Risk of bias: All domain - low, Selection - low, Blinding - low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectnessProtocol outcome 6: Quality of Life - Actual outcome: Nottingham Health Profile (higher values=better; mean (SD) changes in scores from baseline); Group 1: +1.09 (2.57), Group 2: +0.18 (1.94); Risk of bias: All domain - low, Selection - low, Blinding - low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness


Avoidable adverse events, patient and/or carer satisfaction, number of presentations to ED, readmission, reduced GP presentations

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Study Talcott 2011286

Study type RCT (Patient randomised; Parallel)

Number of studies (number of participants) 1 (n=117)

Countries and setting Conducted in USA; Setting: Hospital and home

Line of therapy 1st line

Duration of study Intervention + follow up:

Method of assessment of guideline condition Adequate method of assessment/diagnosis

Stratum Admission avoidance

Subgroup analysis within study Not applicable

Inclusion criteria Adult outpatients with post chemotherapy fever and neutropenia (absolute neutrophil count less than 500µl) that persisted after at least 24 hour.

Exclusion criteria AIDs associated malignancy, neutropenia arising more than 21days after chemotherapy, and intensive chemotherapy requiring bone marrow or peripheral stem cell support.

Recruitment/selection of patients Outpatients at presentation, exhibit no indication for hospitalisation other than fever and neutropenia, such as systemic hypotension, altered mental status, respiratory failure, or inadequate oral fluid intake during 24 hour observation, and have adequately controlled cancer.

Age, gender and ethnicity Age - Median (range): Hospital care: 47 (20-81); early discharge: 47 (25-74). Gender (M:F): Hospital care: 33/33; HAH: 28/19. Ethnicity: not stated

Further population details 1. Frail elderly

Indirectness of population --

Interventions (n=47) Intervention 1: Hospital at home - Hospital at home led by primary care. Patients were supervised by the treating physician with additional assistance available from the research team. Patients at home were required to measure their temperature and blood pressure at least 4 times daily. They were examined by a home care nurse who used a written protocol and was instructed to contact the primary physician if abnormal findings occurred. In addition, a physician examined each home care patient 2 to 4 days after discharge, at least weekly thereafter. Outpatients were readmitted to the hospital whenever a physician felt the patient’s condition warranted it, if the patient requested or it proved infeasible to administer the prescribed antibiotics. Duration: study period. Concurrent medication/care: not feasible (n=66) Intervention 2: Hospital-based care/services. Continued inpatient antibiotic therapy. Duration: study period.

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Study Talcott 2011286

Concurrent medication/care: not stated

Funding Funding not stated

RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: HOSPITAL AT HOME LED BY PRIMARY CARE versus HOSPITAL-BASED CARE/SERVICES Protocol outcome 1: Mortality at during study period - Actual outcome for Early discharge: Mortality at end of study; Group 1: 0/47, Group 2: 0/66; Risk of bias: All domain - Low, Selection - Low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness Protocol outcome 2: Number of admissions to hospital at After 28 days of first admission - Actual outcome for Early discharge: Hospital re-admission at end of study; Group 1: 4/47, Group 2: 0/66; Risk of bias: All domain - Low, Selection - Low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcomes not reported by the study Quality of life at during study period; Avoidable adverse events at during study period; Patient and/or carer satisfaction at during study period; Number of presentations to Emergency Department at during study period; Number of GP presentations at during study period; Readmission up to 30 days; Length of hospital stay at during study period

Study Vianello 2013304



Countries and setting Conducted in Italy; Setting: Hospital and home.

Line of therapy 1st line.

Duration of study Intervention + follow up: Follow-up -3 months.




Inclusion criteria Neuromuscular disease patients with respiratory tract infection and with urgent need of hospitalisation

Exclusion criteria Requirement of critical care with 24 hour surveillance; living outside the geographic area covered by our district nurse service; no non-professional care givers or care giver networks at home; and presence of an advance directive

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declining to undergo intubation and/or CPR.

Recruitment/selection of patients All consecutive neuromuscular disease (NMD) patients who were referred to the ED or to the out-patient clinic between Jan 2009 and Dec2011 with respiratory tract infection and urgent hospitalisation were recruited.

Age, gender and ethnicity Age - Mean (SD): HAH: 44.6 (20.4); HOSPITAL: 46.7 (20.2). Gender (M:F): HAH: 17/9; Hospital: 24/3. Ethnicity: not stated.

Further population details 1. Frail elderly.


Interventions (n=26) Intervention 1: Hospital at home - Hospital at home led by primary care. Non-invasive ventilation (NIV) delivered at home by a portable ventilator; manually and/or mechanically assisted cough; continuous SpO2 monitoring; antibiotic therapy; pulmonology visit at home; district nurse visit at home; telephone access to pulmonologists. Duration: end of study. Concurrent medication/care: not stated. (n=27) Intervention 2: Hospital-based care/services. Patients received usual care, consisting of the same drugs and all other supportive measures delivered to the hospital at home group at the discretion of the ward team. Duration: end of study. Concurrent medication/care: not stated.

Funding Funding not stated.

RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: HOSPITAL AT HOME LED BY PRIMARY CARE versus HOSPITAL-BASED CARE/SERVICES. Protocol outcome 1: Mortality at during study period. - Actual outcome for Admission avoidance: Mortality at 3 months; Group 1: 3/26, Group 2: 4/27; Risk of bias: All domain - Low, Selection - High, Blinding - Low, Incomplete outcome data - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcomes not reported by the study Quality of life at during study period; Avoidable adverse events at during study period; Patient and/or carer satisfaction at during study period; Number of presentations to Emergency Department at during study period; Number of admissions to hospital at After 28 days of first admission; Number of GP presentations at during study period; Readmission up to 30 days; Length of hospital stay at during study period.

D.2 Hospital at Home (Primary & Secondary Care) Study NIKOLAUS 1999216

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Study NIKOLAUS 1999216


Number of participants n=545.

Countries and setting University Hospital of Heidelberg.

Duration of study Follow up for 12 months.



None.

Inclusion criteria Elderly (>65 years) who lived at home before admission.

Had multiple chronic conditions or functional deterioration after convalescence.

At risk of nursing home placement.

Exclusion criteria Terminally ill or severe dementia.

Patients who lived too far away (>15km) for the home intervention team to make regular visits.


Patients over 65 years with acute disease are usually referred to the geriatric centre at the University Hospital of Heidelberg. They are either referred directly by their general practitioner or admitted from the emergency wards of the departments of internal medicine, neurology and surgery.

Eligible patients gave informed consent and randomly assigned to (i) comprehensive geriatric assessment and additional in-hospital and post-discharge follow up treatment by an interdisciplinary home intervention team, (ii) comprehensive geriatric assessment with recommendations, followed by usual care at home or (iii) assessment of activities of daily living and cognition, followed by usual care in hospital and at home. The randomisation was carried out by means of sealed envelopes containing group assignments using a random number sequence.

Baseline characteristics of the subjects were comparable. 30 subjects lost to follow up (and the baseline characteristics of these subjects were comparable to those of the whole study sample.


Mean: 84.1 years.

Gender.

(% of F): 73.4%.



Extra comments -

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Study NIKOLAUS 1999216


Interventions Intervention 1: Hospital at home-consisted of 3 nurses, a physiotherapist, an occupational therapist, asocial worker and a secretary. The tea, worked closely with hospital staff and the primary care physician. While the patient was in hospital the team gave them additional treatment (such as additional training in washing, eating, dressing and/or walking). One home visit was carried out during the hospital stay to evaluate the patient’s home (for example, for safety hazards) and to prescribe technical aids, when necessary. After discharge, the team provided treatment (such as physiotherapy/occupational therapy).

The mean treatment period was 7.6 days (range 1 – 41 days). At least 1 home visit was carried out within 3 days of discharge. Three months after discharge, a follow up visit was made to check whether recommendation were being implemented, home care continued and technical aids used, and to identify any new problem.

Intervention 2: Hospital based care/services-assessment of activities of daily living and cognition, followed by usual care in hospital and at home.

Funding Sozialministerium Baden Wurttemberg (Government Funding).

RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: HOSPITAL AT HOME (PRIMARY & SECONDARY) Versus USUAL CARE.

Protocol outcome 1: Length of stay. - Actual outcome: Length of hospital stay, days; Group 1: Mean (range): 33.5 (30.4-36.5); Group 2: Mean (range): 42.7 (39.8-45.6); Risk of bias: All domain - high, Selection - high, Blinding - low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 2: Quality of Life. - Actual outcome: Activities of daily living score; Group 1: Mean (range): 81.2 (77.8-84.6); Group 2: Mean (range): 80.9 (78.1-83.8); Risk of bias: All domain - high, Selection - high, Blinding - low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 3: Patient Satisfaction. - Actual outcome: Self-perceived score/life satisfaction score; Group 1: Self-perceived health score: Mean (range): 3.7 (3.4-4.0), Life satisfaction score: Mean (range): 3.9 (3.6-4.2); Group 2: Self-perceived health score: Mean (range): 3.0 (2.8-3.2), Life satisfaction score: Mean (range): 3.2 (2.9-3.4); Risk of bias: All domain - high, Selection - high, Blinding - high, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 4: Readmission. - Actual outcome: Rehospitalisation; Group 1: 43/140 (30.7%); Group 2: 45/141 (31.9%); Risk of bias: All domain - high, Selection - high, Blinding - low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness


Mortality, avoidable adverse events, carer satisfaction, number of presentations to ED, number of avoidable admissions, reduced GP presentations.

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D.3 Step up – Step down/Community Hospital Study APPLEGATE 199016


Number of participants Geriatric Assessment Unit (n=78).

Control Group (n=77) n=155.

Countries and setting Geriatric Assessment Unit, Baptist Memorial Hospital, Memphis, USA.

Duration of study July 1985 – June 1987 was the enrolment period; patients followed up for 1 year thereafter.



Yes. Stratification performed before randomisation according to whether the patient, the family or the consulting physician thought that the patient had a higher or lower risk of immediately going to a nursing home.

Inclusion criteria At risk for nursing home placement.

To have potentially reversible functional impairment in more than one activity of daily living, or both.

Age of 65 or older.

Loss of independence in more than one activity of daily living.

Willingness to participate in a randomised study and give signed informed consent.

Access to a primary physician willing to resume care of the patient at discharge.

Exclusion criteria Medical problems that were unstable or required continued short term monitoring.

If their survival was estimated to be less than six months.

If they had serious chronic mental impairment.

If a nursing home placement was considered inevitable.


278 referrals received from physicians and social work personnel, to the Hospital. Of which 123 were considered ineligible. The remaining 155 patients were randomly assigned, 77 to the control group and 78 to the geriatric assessment unit.

Further details: baseline characteristics of patients well-balanced across both groups; all completed the study (no loss/drop outs recorded).


Mean: 78.8 years (range: 61-100).

Gender.

(% of F): 77%.

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Study APPLEGATE 199016

Nationality.

White (84.5%), other (15.5%).

Further population details Most common diagnoses at referral: hip fractures in 28 patients, other fractures in 23, other conditions requiring orthopaedic surgery in 9, conditions requiring non-orthopaedic surgery in 14, circulatory disorders in 21, stoke in 15, musculoskeletal disorders in 9, psychiatric disorders in 7, endocrine disorders in 6 and miscellaneous medical disorders in 17.

Extra comments -


Interventions (n=78) Intervention 1: Hospital at home- The Geriatric Assessment Unit: 10-bed unit in rehabilitation hospital (occupies a separate building from main hospital). Primary objective of the unit was to improve health and functional status sufficiently that patients at risk of institutionalisation could avoid placement in a nursing home. Within the unit, an interdisciplinary assessment of medical, social and psychological function was completed within 72 hours of admission by a team of physicians (university faculty and fellows), rehabilitation nurses, physical therapists, occupational therapist, psychologists, social workers, nutritionists and specialists in speech therapy and audiology.

After the assessments were completed, the team determined at the first of a series of weekly meetings whether the patient was a candidate for a specific treatment, rehabilitation or both. If medical treatment was required, the patient was either treated in the unit or returned to the acre of the referring physician. Any patient with a defect in vision, hearing, or speech was referred to the appropriate therapist .If the patients needed rehabilitation care, a rehabilitation plan with specific goals was developed, and the patients’ progress was revaluated weekly. All patients receiving rehabilitation care were required were required to have a degree of impairment such that physical, occupational or recreational therapy was needed in some combination three times a day in order to meet Medicare requirements. When patients reached their rehabilitation goals or attained a stable level of function, they were discharged without any subsequent services from the geriatric-assessment-unit team.

(n=77) Intervention 2- Standard care: Neither the staff members of the geriatric assessment unit nor the investigators in the study were involved in the care of the patients in the control group after randomisation. Instead, the controls received the usual care provided by their physicians. There were no differences between groups in the specialties of the primary physicians providing care for their patients; two thirds of the patients in each group received primary care from internists in the community.

The patients received a wide range of services after discharge from the acute care hospital, including home health care and care in other rehabilitation units.

Funding None stated.

RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: STEP UP/STEP DOWN versus STANDARD CARE. Protocol outcome 1: Mortality. - Actual outcome: Mortality at 6 months; differences between two groups greatest at 6 months (p=0.08) but diminished thereafter.

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Study APPLEGATE 199016

Group 1: 8/78 patients; Group 2: 1/77 patients; Risk of bias: All domain - low, Selection - low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 2: Length of Stay. - Actual outcome: Length of stay in acute hospitals; Group 1: 69 days (SD not reported); Group 2: 74 days (SD not reported); Risk of bias: All domain - low, Selection - low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 3: Quality of Life. - Actual outcome: Functional Status;

Geriatric assessment unit had significantly more improvement (P<0.05) than the control group in regard to three basic self-care activities (bathing, dressing and the ability to transfer) during the six months after randomisation and tended to have less deterioration in one other activity (the ability to administer medications).

Risk of bias: All domain - high, Selection - low, Blinding - high, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness


Avoidable adverse events; patient and/or carer satisfaction; re-admission; number of presentations to ED; Number of unnecessary admissions; reduced GP presentations.

Study GARASEN 2007110 GARASEN 2008109


Number of participants Community Hospital=72.

General Hospital=70 n=142.

Countries and setting Sobstad Nursing Home (reassigned to become a community hospital) and St Olavs University Hospital, Norway.

Duration of study August 2003 – May 2004. Follow up for 12 months.



None reported.

Inclusion criteria Patients aged 60 years or more admitted to the general hospital due to an acute illness or an acute exacerbation of a known chronic disease.

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Probably be in need of inward care for more than 3 to 4 days.

Admitted from their own homes.

Expected to return home when inward care was finished.

Exclusion criteria Severe dementia.

A psychiatric disorder needing specialised care 24 hours a day.


When an eligible patient was identified and accepted for inclusion, a blinded randomisation was performed by the Clinical Research Department at the Faculty of Medicine using random number tables in blocks to ensure balanced groups.


Community Hospital (Mean=80.8. Median=81.5).

Assigned General Hospital (Mean=81.3. Median=81).

Gender.

Community Hospital (Males=34. Females=102).

Assigned General Hospital (Males=27. Females=43).


Further population details Activities of Daily Living.

Community Hospital (Mean=2.24).

Assigned General Hospital (Mean=2.05).

A non-significant difference (p=0.27).

Extra comments -


Interventions (n=72) Intervention 1: Hospital at home- Intermediate Care Intervention: The experimental intervention was based on individualised intermediate care including evaluation and treatment (‘care’ and ‘cure’) of each patient’s diseases. However, the main focus was to improve the patients’ ability to manage daily activities when returning home.

On admission to the community hospital the physicians performed a medical examination of the patients and a careful evaluation of available earlier health records from the admitting general practitioner, the general hospital physicians and the community home care services. The communication with each patient and his family focusing on physical and mental challenges was also essential to understand the needs and level of care.

Intermediate care at the community hospital was compared to conventional care in general hospital beds at medical, surgical and orthopaedic departments.

(n=70) Intervention 2: Hospital based care/services-General Hospital: Traditional prolonged care at a hospital.

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Funding Central Norway Regional Health Authority.

RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: STEP UP/STEP DOWN (COMMUNITY HOSPITAL) versus STANDARD CARE.

Protocol outcome 1: Readmission. - Actual outcome: Readmission for the same disease; Group 114/72 (19.4%); Group 2: 25/70 (35.7%); Risk of bias: All domain - low, Selection - low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 2: Length of Stay. - Actual outcome: Number of days of care after randomisation; Group 1:31 days (95% CI 26.1-34.7); Group 2: 29.8days (95% CI 23.2-36.4); Risk of bias: All domain - low, Selection - low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 3: Mortality. - Actual outcome: Mortality within 6 months; Group 1:9/72 (12.5%); Group 2: 14/70 (20%). Risk of bias: All domain - low, Selection - low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

- Actual outcome: Mortality within 12 months; Group 1: 13/72 (18.1%); Group 2: 22/70 (31.4%); Risk of bias: All domain - low, Selection - low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness


Avoidable adverse events; quality of life; patient and/or carer satisfaction; number of presentations to ED; number of unnecessary admissions; reduced GP presentations.

Study THOMAS 1993289


Number of participants Experimental group (Community Hospital) = 68.

Control group (no intervention) = 64 n=132.

Five patients refused assessment (control group=2, experimental group=3) and seven patients were lost to follow up (control=4, experimental=3).

Countries and setting A non-academic affiliated 503-bed community hospital.

Duration of study Follow up for 6 months.

Stratum Overall.

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None reported.

Inclusion criteria All patients over the age of 70 years admitted to a 503-bed community hospital were eligible.

Exclusion criteria Refusal of consent.

Admission to intensive care unit, coronary care unit, an obvious terminal illness, renal haemodialysis.

Place of residence greater than 50 miles from the hospital.


Study patients were similar in both groups at randomisation.


Experimental group (Community Hospital): 76 (+/- 5.4).

Control group: 77 (+/- 5.4).

Gender.

Experimental group (Community Hospital): Male: 22; Female 40.

Control group: Male: 24; Female 34.

Race.

Experimental group (Community Hospital): White: 49; Black: 13.

Control group: White: 43; Black: 15.


Extra comments -


Interventions (n=68) Intervention 1: Community Hospital- received individual assessments from each team member consisting of a physician, geriatric nurse specialist, pharmacist, and physical therapists. Team discussions of each patient led to formal recommendations placed in the patients charts. An additional copy of the consultation was mailed to the attending physicians’ office. The team continued to monitor progress of the experimental group.

(n=64) Intervention 2: In-hospital treatment then discharged. Received no recommendations and no subsequent visits.

Funding Not stated.

RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: STEP UP/STEP DOWN versus STANDARD CARE.

Protocol outcome 1: Mortality. - Actual outcome: Death at 6 months; Group 1:3/62 (6%); Group 2: 12/58 (21%); Risk of bias: All domain - high, Selection - high, Blinding - low, Incomplete outcome

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data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

- Actual outcome: Death at 12 months; Group 1:7/68 (10%); Group 2: 13/64 (20%); Risk of bias: All domain - high, Selection - high, Blinding - low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 2: Length of Stay. - Actual outcome: Length of hospital stay; Group 1:9 days; Group 2: 10.1 days; Risk of bias: All domain - high, Selection - high, Blinding - low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 3: Readmissions. - Actual outcome: Readmissions in 6 months; Group 1:0.3 per patient; Group 2: 0.6 per patient; Risk of bias: All domain - high, Selection - high, Blinding - low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 4: Quality of Life. - Actual outcome: Functional activity scores using Katz ADL scale; Group 1: 61% (36/59) remained same. 17% (10/59) worsened. 22% (13/59) showed improvement;

Group 2: 70% (32/46) remained the same. 23% (10/46) worsened. 7% (4/46) showed improvement.



Avoidable adverse events; patient and/or carer satisfaction; number of presentations to ED; number of unnecessary admissions; reduced GP presentations.

Study YOUNG 2007322

Study type RCT (single-blind, randomised, prospective trial).

Number of participants Community Hospital=280.

General Hospital=210 n=390.

Countries and setting Community hospitals in five geographical areas in urban and rural settings in the midlands and North England.

Duration of study November 2000 – August 2003 patient identification. Follow up for 6 months.



None reported.

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Study YOUNG 2007322

Inclusion criteria Address within the catchment area of the relevant community hospital.

In the opinion of their attending senior physician, were medically stable and in need of post-acute rehabilitation care before anticipated home discharge.

Exclusion criteria Patients with features of medical instability (pyrexia, breathlessness at rest, history of chest pain within 48 hours, or need for IV medications).

Patients who were drowsy or unconscious.

Patients requiring stroke unit rehabilitation with a specialists or treatment in other departments such as surgery or coronary care.

Patients who needed new residential new residential or nursing home placements.


773 elderly patients who had been emergently admitted to elderly care departments (four general hospital sites) or a combined elderly and medical unit (one general hospital site) were identified and monitored. Of these, 490 were recruited, 280 randomised to community hospital care and 210 to usual care. 421 (86%) received the treatment to which they were allocated.

Further details: the characteristics were of the groups were similar at baseline. Lost/drop outs – Community 11/280; Usual care 11/210.


Community Hospital (Median=86. Range=81-90).

General Hospital (Median=86. Range=82-90).

Gender.

Community Hospital (Males=83. Females=197).

General Hospital (Males=69. Females=141).



Extra comments -


Interventions (n=280) Intervention 1: Community Hospital - The seven participating community hospitals in the five sites ranged from a consultant-led rehabilitation hospital in an urban setting to small, rural, general practitioner-led units. The community hospitals provided a multi-disciplinary rehabilitation approach with multidisciplinary assessment and treatment, individualised care plans, involvement of therapists, shared coverage between consultants and general practitioners, and close involvement of social service staff.

(n=210) Intervention 2: General Hospital: Usual care consisted primarily of an extended general hospital stay with multidisciplinary care but could include transfer to other post-acute services according to existing local operational policies.

Funding Department of Health.

RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: STEP UP/STEP DOWN versus STANDARD CARE.

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Study YOUNG 2007322

Protocol outcome 1: Length of Stay. - Actual outcome: Length of hospital stay care after randomisation; Community Hospital: Median: 22 days (range: 1-195; interquartile range: 11-45); General Hospital: Median: 20 days (range: 1-230; interquartile range: 10-34); Risk of bias: All domain - low, Selection - low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 2: Quality of Life. - Actual outcome: NEADL Scale as a measure of independence at 6 months; Community Hospital: Median 20 (IQR 9-32); General Hospital: Median 20 (IQR 6-32). Risk of bias: All domain - low, Selection - low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

- Actual outcome: Barthel Index (functional activity restriction) at 6 months; Community Hospital: Median 16 (IQR 13-18); General Hospital: Median 16 (IQR 12-18); Risk of bias: All domain - low, Selection - low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 3: Mortality. - Actual outcome: Death at 6 months; Community Hospital: 73/280 (26.1%); General Hospital: 64/210 (30.5%); Risk of bias: All domain - low, Selection - low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 4: Patient satisfaction. - Actual outcome: Patient satisfaction. The reported patient satisfaction was similar for both groups. At 1 week after hospital discharge, the community hospital group showed greater satisfaction with the statement ‘I am happy with the amount of recovery I have made’; Risk of bias: All domain - low, Selection - low, Blinding - Low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness


Avoidable adverse events; carer satisfaction; readmission; number of presentations to ED; number of unnecessary admissions; reduced GP presentations.

Virtual Wards

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Study DHALLA 201483

Study type RCT; parallel-group randomised trial.


1 (n=1923); ‘High-risk population’ randomised into 2 groups (ratio 1:1): Virtual Ward (n=963) or Usual Care (n=960).

Countries and setting General internal medicine wards of 4 participating hospitals in Toronto, Canada.

Duration of study Between June 2010 to May 2013.



n/a

Inclusion criteria Aged ≥18 years; being discharged from the general internal medicine ward of any of the 4 participating hospitals; at high risk of re-admission (as determined by LACE [length of stay, acuity of admission, comorbidities, and emergency department visits in the previous 6 months] score ≥10), and resided within the boundaries of the Toronto Central Local Health Integration Network.

Exclusion criteria Being discharged to a rehabilitation or complex continuing care facility, if neither they nor anyone they could designate could speak English, if they had been previously enrolled in the study, of if they did not wish to participate.


Patients randomised when discharge was imminent or immediately after discharge. 30143 patients were assessed for eligibility at the 4 hospitals. Of the 6559 eligible patients, 1932 were randomly assigned to one of the two groups. The randomisation list was stratified by discharge site and homelessness.

Age, gender and ethnicity Usual Care (n=960) = Age – Mean (SD): 71.3 years (16.0). Gender (M/F): 1/1. Ethnicity: no information given.

Virtual Ward (n=963) = Age – Mean (SD): 71.2 years (16.1). Gender (M/F): 1/1. Ethnicity: no information given.

Further population details No important differences between the two groups in terms of demographics. Reason for hospitalisation: 10% heart failure; 90% other.

Extra comments


Interventions (n=963) Intervention 1: Virtual ward- in addition to receiving usual care, patients assigned to the virtual ward group were admitted to the virtual ward on the day they were discharged home. They were contacted by a team member the next day, provided with written information about the services available. Patients could call the relevant member of the team during business hours; or call was sent to the VW physician’s pager after hours. Team consisted of care coordinators, part-time pharmacist, part-time nurse, full-time physician, clerical assistant. Most of the staff worked for the Toronto Central Community Care Access Centre. The team met every morning to discuss newly admitted and current patients and to design and execute individualised care plans. Patients could be assessed by phone, at home, in a clinic at the hospital where the VW team was based, or alternative location (for example, GP office). Patients were discharged from VW when the team believed they were ready for discharge or when it was clear that they were unwilling to further engage with the team.

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Study DHALLA 201483

(n=960) Intervention 2- Usual care: typewritten structured discharge summary given to patient at time of discharge and also sent to GP, a prescription when indicated, counselling from the resident physician or other members of the health care team, arrangements for homecare as needed, and recommendations or appointments for follow-up care with the patient’s primary care and specialist physicians. Follow-up at a post-discharge clinic was not a routine practice at any of the hospitals but could have been arranged at the discretion of the discharging physicians.

Concurrent medication/care: both received usual care but VW group received extra VW team support.

Retrospective analysis of data by authors indicated that VW team provided high intensity of care. Patients were discussed at the MDT meetings an average of 6.3x (SD=2.1) and received an average of 2.8 home visits (SD=0.95). This does not include potential extra care provided by home care contractors or physicians not associated with VW. The mean length of stay in VW was 35.5days (SD=27.0).

Funding Canadian Institutes of Health Research, the Ontario Ministry of Health and Long-Term Care, the Green Shield Canada Foundation, the University of Toronto Department of Medicine, and the Academic Funding Plan Innovation Fund.

RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: VIRTUAL WARD versus USUAL CARE. Protocol outcome 1: Mortality (at 30 days) reported as number/total number. (%). - Actual outcome: Death; Group 1: n=40/958 (4.2); Group 2: n=47/955 (4.9); Risk of bias: All domain - high, Selection - high, Blinding - low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 2: Readmission (at 30 days). - Actual outcome: readmission; Group 1: n=182/961 (18.9), Group 2: n=204/958 (21.3); Risk of bias: All domain - high, Selection - high, Blinding - low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Protocol outcome 3: ED visits (at 30 days). - Actual outcome: ED visits; Group 1: n=270/961 (28.1), Group 2: n=284/959 (29.6); Risk of bias: All domain - high, Selection - high, Blinding - low, Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low, Subgroups - Low; Indirectness of outcome: No indirectness

Note: outcomes closest to discharge reported that is, 30 days. Paper also reports the same outcomes at 90 days, 6 months, and 1 year.


Avoidable adverse events, quality of life, patient and/or carer satisfaction, length of stay, number of unnecessary admissions, reduced GP presentations.

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Appendix E: Economic evidence tables

E.1 Hospital at Home

E.1.1 Admission avoidance

Study Aimonino-Ricauda 20089

Study details Population & interventions Costs Health outcomes Cost effectiveness

Economic analysis: CCA (health outcome: various outcomes )

Study design: RCT

Approach to analysis: within-trial analysis of individual patient level cost and outcome data on Intention-to-treat basis.

Perspective: Italian health care provider

Follow-up: 6 months

Discounting: Costs: n/a; Outcomes: n/a

Population: (n=104)

Elderly patients aged > 75 years, with exacerbation of COPD who were assessed in the ED for at least 12 to 24 hours and with stable clinical condition.

Cohort settings:

Mean age:

Intervention 1: 79.2 years (SD=3.1)


Male:

Intervention 1: 75%

Intervention 2: 56%

Intervention 1: (n=52)

Admission to general medical ward

Total costs (mean per patient):

Intervention 1: £1,302

Intervention 2:£1,100

Incremental (2−1): -£202

(95% CI: NR; p=0.38)

Cost per day (mean per patient)

Intervention 1: £142

Intervention 2:£95


(95% CI: NR; p=0.002)

Currency & cost year:

2005 euros converted to 2005 US dollars using currency exchange rate (presented here as 2005 UK pounds(a))

Cost components incorporated:

From clinical review

Mortality (mean per patient):

Intervention 1: 23%

Intervention 2: 17%

Incremental (2−1): -6%

(95% CI: NR; p=0.72)

Hospital admission (reported as re-admission)

Intervention 1: 87%

Intervention 2: 42%

Incremental (2−1): -45%

(95% CI: NR; p=0.001)

Days between discharge and re-admission

Intervention 1: 37 days


Incremental (2−1):41 days

(95% CI: NR; p=0.005)

ICER (Intervention 2 versus Intervention 1):

n/a

Analysis of uncertainty:


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Admission to a physician-led, substitutive clinical unit model at a geriatric home under the care of a team of geriatricians, nurses, physiotherapists, social workers and counsellors (hospital-at-home).

Hospital-at-home patients are considered hospital patients and the hospital, which retains legal and financial responsibility, provides all services.

Staff time (geriatricians, nurses, counsellors, dieticians, social workers)

Hospital stay (beds, staff, examinations, medications, rehabilitation, miscellaneous expenses)

ED visits

Change in geriatric depression scale

Intervention 1: 0.7

Intervention 2: -3.1

Incremental (2−1): -2.6

(95% CI: NR; p=0.00)

Change in Nottingham health profile score

Intervention 1: 0.8

Intervention 2: 3.6

Incremental (2−1): 2.8

(95% CI: NR; p=0.04)

Change in activities of daily living score




(95% CI: NR; p=0.10)

Change in mini mental state examination score




(95% CI: NR; p=0.88)

Change in mini-nutritional assessment score

Intervention 1:-1.2

Intervention 2:-1.7


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(95% CI: NR; p=0.59)

Change in relatives’ stress scale score

Intervention 1:2.6

Intervention 2:4.6

Incremental (2−1):2.0

(95% CI: NR; p=0.16)

Satisfaction very good/excellent at discharge

Intervention 1:88%

Intervention 2: 94%

Incremental (2−1): 6%

(95% CI: NR; p=0..83)

Data sources

Health outcomes: RCT study with baseline characteristics ascertained at randomisation. Follow-up visit at 6 months with health outcomes recorded. Data were also collected from the hospital medical records for hospitalisation, mortality, resource use and costs. Quality-of-life weights: not used (CCA). Cost sources: Resource use and unit costs were based on the hospital medical records data.

Comments

Source of funding: Public funding Applicability and limitations: QALYs are not used as an outcome measure. Some uncertainty regarding the applicability of Italian resource use (2005) and unit costs (2005) to the NHS context. Within-trial analysis; so does not reflect all the evidence available for this comparison. Local unit costs from hospital records were used; so may not reflect the National unit costs. Uncertainty was not appropriately addressed and no sensitivity analysis undertaken.

Overall applicability(b): partially applicable Overall quality(c): potentially serious limitations

Abbreviations: CCA: cost–consequence analysis; 95% CI: 95% confidence interval; COPD: chronic obstructive pulmonary disease; ED: emergency department; ICER: incremental cost-effectiveness ratio; NA: not applicable; NR: not reported; QALYs: quality-adjusted life years. (a) Converted using 2005 purchasing power parities.223 (b) Directly applicable/Partially applicable/Not applicable. (c) Minor limitations/Potentially serious limitations/Very serious limitations.

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Study Mendoza 2009202


Economic analysis: CCA (health outcome: various health outcomes)

Study design: RCT

Approach to analysis: Analysis of individual level data for health outcomes and resource use. Unit costs applied.

Perspective: Spain direct medical costs

Follow-up 12 months


Population:

elderly patients (>65 years) presenting to the ED with decompensated heart failure (HF)

Cohort: (n=71)

Mean age (SD):

Intervention 1: 79.9 (6.3)

Intervention 2: 78.1 (6.2)

Male: 29.8%


Inpatient hospital care (IHC)


Hospital at home (HaH)


Index episode



Incremental (2−1): -£1,772

(95% CI: NR; p<0.001)

Follow-up (12 months)




(95% CI: NR; p<0.001)


2008 Euros (presented here as 2008 UK pounds(a))


Hospital stay for index episode

Medications

Diagnostic tests

Consumables

Transport

Visits to HF clinic

Visits to primary care physician

Mortality:

Intervention 1: 3 (8.8%)


Incremental (2−1): -3.4%

(95% CI: NR; p=0.67)

Readmission for HF:

Intervention 1: 17 (50%)



(95% CI: NR; p=0.42)

Combined clinical outcome:




(95% CI: NR; p=0.88)

Functional status (variation in BI):

Intervention 1: 4.7 (95% CI: -2.2; 11.5)

Intervention 2: 4.0 (95% CI: -0.9; 8.9)


(95% CI: NR; p=0.21)

health-related quality of life (HRQoL) [Idem SF-36 physical component]

Intervention 1: 2.2 (95% CI: --1.9; 6.4)

Intervention 2: 3.6 (95% CI: --0.5; 7.7)


(95% CI: NR; p=0.47)


NA


No sensitivity analysis conducted.

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Study Mendoza 2009202


Visits to ED

Re-admissions

HRQoL [Idem SF-36 mental component]

Intervention 1: 2.8 (95% CI: -2.4; 8.0)

Intervention 2: 4.0 (95% CI: -0.9; 8.9)


(95% CI: NR; p=0.38)

Data sources

Health outcomes: Baseline: nursing and clinical evaluation, laboratory tests and ECG undertaken and functional status (BI) and HRQoL (SF-36) data collected. Follow-up: clinical data collected from patients at months 1, 3, 6 and 12, blood tests, functional status (BI) and HRQoL (SF-36) re-assessed at 12 months. Cost sources: using data collected from hospital records and using questionnaires administered during follow-up. Unit costs were based on compensation charged by Basque Health Service-Osakidetza (for hospital stays, visits and diagnostic tests) and hospital pharmacy reference prices (medications).

Comments

Source of funding: Grant from Caja Vital Kutxa (financial institution). Applicability and limitations: QALYs are not used as outcome measure. Spanish resource use data (2006-2007) and unit costs (2008), so some uncertainty about the applicability of resource use and costs to current NHS context. RCT-based analysis, so from one study by definition therefore not reflecting all evidence in area. Some local costs used; so there is uncertainty as to whether these will reflect national costs. Some uncertainty about whether time horizon is sufficient to capture all benefits and costs.


Abbreviations: CCA: cost–consequences analysis; 95% CI: 95% confidence interval; da: deterministic analysis; ED: emergency department; HF: Heart failure; HRQoL: Health-Related quality of life; ICER: incremental cost-effectiveness ratio; NA: not applicable; NR: not reported; pa: probabilistic analysis; QALYs: quality-adjusted life years; SF-36: Short-Form 36. (a) Converted using 2008 purchasing power parities.223 (b) Directly applicable/Partially applicable/Not applicable (c) Minor limitations/Potentially serious limitations/Very serious limitations.

Study Richards 2005242


Economic analysis: CCA (health outcome: various outcomes)

Population:

Patients presenting to the ED at Christchurch Hospital, New Zealand with a clinical




From clinical review:

Duration until discharge:

Intervention 1: 2 days (range 0-10)


NA

Analysis of uncertainty: No sensitivity

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Study design: RCT

Approach to analysis: Within-trial analysis with individual patient data on both costs and outcomes collected and analysed using univariate analysis.

Perspective: New Zealand funder’s perspective (direct medical costs)

Follow-up: 6 weeks


diagnosis of community acquired pneumonia (CAP) that is mild to moderately severe and who has been assessed as low risk (CURB-65 score of 0-2, corresponding to mortality risk of 0.7-9.2%).

Cohort settings: (n=55 (ITT), 49 (PP))

Mean age:

Intervention 1: 49.8 years


Male:

Intervention 1: 13/25 (52%)

Intervention 2: 13/24 (54.2%)


Standard treatment with antibiotics in hospital following initiation of treatment at the ED.


Treatment at home delivered by primary care teams under the Extended Care @Home (EC@H) program which provides extended medical


(95% CI: NR; p=NR)


2003 New Zealand Dollars (presented here as 2003 UK pounds(a))


Staff time

Transport

Equipment

Pharmaceuticals

Support services (such as home help)

Administration

Laboratory tests

Radiological examinations

Intervention 2: 4 days (range 1-14)

Incremental (2-1): 2 days

(95% CI: NR; p=0.004)

Duration of IV antibiotic administration:



Incremental (2-1): 1 day

(95% CI: NR; p=0.22)

Duration of oral antibiotic administration:



Incremental (2-1): 2 days

(95% CI: NR; p=0.22)

Functional outcomes (SF-12 mental component):

At 2 weeks

Intervention 1: 48.6


Incremental (2-1): -0.3

(95% CI: NR; p=0.91)

At 6 weeks

Intervention 1: 51


analysis reported

No significant difference was observed in patient rated symptoms at 2 weeks. There was significant difference in sleep disturbance in favour of hospital treatment (p<0.001) at two weeks which did not persist at 6 weeks. There was also no significant difference in time to resolution of fever, tachycardia and tachypnoea.

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and nursing care to patients in their home. The team provides IV antibiotic service using standard cannula, home support service, short-term home nursing and mobile diagnostic testing. The patients had a daily visit from the GP and at least twice daily visit from a nurse. Patients’ Chest X-ray was reviewed initially by a respiratory physician. Patients were given a 24-hour telephone number to contact in case of emergency.


(95% CI: NR; p=0.81)

Functional outcomes (SF-12 physical component):

At 2 weeks




(95% CI: NR; p=0.45)

At 6 weeks




(95% CI: NR; p=0.18)

Adverse events:

See clinical review

Patient satisfaction:

Intervention 1: 60% “very happy” with their care

Intervention 2: 100% “very happy” with their care

Incremental (2-1): 40%

(95% CI: NR; p=0.001)

Data sources

Health outcomes: Randomised controlled trials with baseline data collected at trial entry. Outcome measures included general functioning (SF-12 score), duration to

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discharge, duration of IV antibiotics and subsequent oral antibiotics administration, self-rated symptom severity, complications and patient satisfaction. Data on self-rated symptom severity, general functioning and adverse events were recorded daily. Data on duration of admission and antibiotics were extracted from the case records. Patients were contacted by telephone at 2 and 6 weeks after presentation to record satisfaction, self-rated symptom severity, and functional outcome (SF-12).Quality-of-life weights: SF-12 utility data were collected from patients but not combined with costs in a full cost-utility analysis. Cost sources: resource use data were collected from the EC@H data for the home care group patients. Victorian DRG costs were used for the hospital treatment group.

Comments

Source of funding: NR. Applicability and limitations: There is uncertainty about the applicability of resource use (2002-2003) and unit costs (2003) from New Zealand to the NHS context. QALYs were not used as an outcome measure. Within-trial analysis so does not reflect all the evidence available for this comparison. The short time horizon (6 weeks) may not reflect all potential differences in costs and outcomes. Unit costs from EC@H service records were used to calculate the costs for patients in the home treatment group. It is not clear whether these costs are national level. Univariate analysis was used in the comparison and no sensitivity analysis was undertaken.


Abbreviations: CCA: cost–consequence analysis; 95% CI: 95% confidence interval; ED: emergency department; ICER: incremental cost-effectiveness ratio; NR: not reported; QALYs: quality-adjusted life years; SF-12: short form-12. (a) Converted using 2003 purchasing power parities.223 (b) Directly applicable/Partially applicable/Not applicable. (c) Minor limitations/Potentially serious limitations/Very serious limitations.

Study Tibaldi 2009296


Economic analysis: CCA (health outcome: various including mortality, quality of life, depression, functional, nutritional and cognitive status )

Study design: RCT

Approach to analysis:

Within-trial analysis of costs and outcomes.

Population:

Patients, 75 years or older, with a pre-existing diagnosis of CHF and persistent functional impairment indicative of New York Heart Association (NYHA) class III or IV.

Cohort settings: n=101

Mean age:





(95% CI: NR; p<0.001)

Cost per day (mean per patient):



Mortality (6-months):

Intervention 1: 15%

Intervention 2: 15%

Incremental (2−1): 0

(95% CI: NR; p=0.83)

See clinical review for the other health outcomes


n/a


No sensitivity analysis is reported.

The authors reported that a proportion of patients in the GMW arm were institutionalised on discharge (16%) for an average of 26 days at a mean cost per day of £115. Adding this cost to the GHHS arm

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Parametric tests (paired and unpaired t-test was used for analysing costs.

Perspective: Italian Healthcare system

Follow-up: 6 months

Treatment effect duration(a): 6 months




Male:

Intervention 1: 57%

Intervention 2: 46%


Routine hospital care in a general medical ward (GMW)


Hospital-led geriatric hospital-at-home service (GHHS) provided by a multidisciplinary team (4 geriatricians, 13 nurses, 3 physiotherapists, 1 social worker, 1 counsellor).


(95% CI: NR; p=NR)


2005 Euros (presented here

as 2005 UK pounds(b))


Hospital costs (including costs for beds, staff time, examinations, medications and rehabilitation, non-sanitary and administrative costs were also included.

GHHS costs included the cost of staff time, transportation of equipment and patients to and from hospital and administrative costs

would increase the saving in mean total cost per patient from £217to £226.

Data sources

Health outcomes: Within trial analysis with data on quality of life, depression, functional and nutritional status and clinical symptoms collected at baseline and at 6 months follow-up. Six-month mortality was also reported. Quality-of-life weights: n/a. Cost sources: hospital cost data were collected from the official hospital medical cost database.

Comments

Source of funding: NR. Applicability and limitations: Cost-consequences analysis, so QALYs are not used as outcome. Some uncertainty about the applicability of resource use and unit costs from Italy in 2005 to the current NHS context. RCT-based analysis so from one study by definition therefore not reflecting all evidence in area. There is also some uncertainty about whether time horizon is sufficient to reflect all the possible downstream differences in costs and outcomes. The sources of unit costs are not clearly described, so not clear whether they are local or national unit costs. No sensitivity analysis is reported.

Overall applicability(c): Partially applicable Overall quality (d): Potentially serious limitations

Abbreviations: CCA: cost–consequence analysis; CHF: Chronic heart failure; 95% CI: 95% confidence interval; ICER: incremental cost-effectiveness ratio; NR: not reported; QALYs: quality-adjusted life years. (a) For studies where the time horizon is longer than the treatment duration, an assumption needs to be made about the continuation of the study effect. For example, does a difference in utility between groups during treatment continue beyond the end of treatment and if so for how long. (b) Converted using 2005 purchasing power parities.223

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(c) Directly applicable/Partially applicable/Not applicable. (d) Minor limitations/Potentially serious limitations/Very serious limitations.

Study Thornton 2005292 and Elliott 2005102


Economic analysis: CEA (health outcome: proportion of patients with < 0% decline in FEV1)

Study design: Retrospective observational study


Individual patient data analysis for both costs and outcomes.

Perspective: UK NHS Trust (secondary care provider)

Time horizon/Follow-up: one year

Treatment effect duration(a): one year


Population:

Adults (> 16 years) with confirmed cystic fibrosis (CF) who experienced at least one respiratory exacerbation during the study period, identified from Manchester Adult CF Centre.

Cohort settings: (n=116)

Mean age:

Intervention 1: 26 years



Male:

Intervention 1: 58.8%




Hospital treatment with intravenous (IV) antibiotics, where the patient received >60% of the treatment courses at hospital


Home treatment with IV antibiotics, where the patient received >60% of






(95% CI: NR; p=NR)


2002 UK pounds.


Hospital stay, clinic appointments, laboratory tests, standard home kits, staff time, IV antibiotics

proportion of patients with < 0% decline in FEV1:



Intervention 3: 50%


(95% CI: NR; p=NR)

proportion of patients with < 2% decline in FEV1:





(95% CI: NR; p=0.045)


£46,098 per extra patient with < 0% decline in FEV1

95% CI: -£362,472 to £374,044

£37,885 per extra patient with <2% decline in FEV1

95% CI: £1,236 to £269,023


Bootstrapping of cost data was used to calculate CIs and represent uncertainty

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Study Thornton 2005292 and Elliott 2005102


the treatment courses at home.


Both home and hospital treatment with IV antibiotics, where the patient received almost equal amounts of home and hospital treatment

Data sources

Health outcomes: Observational data analysis using univariate tests (independent samples t-test, ANOVA and Chi-Sqaure). Quality-of-life weights: NA. Cost sources: resource use data collected from hospital records, ward diaries and a time and motion study. Unit costs were based on both national and local sources including BNF, hospital supplies catalogue and hospital finance records.

Comments

Source of funding: institutional funding. Applicability and limitations: CEA, so QALYs are not used as outcome. The perspective is that of an NHS trust only and does not include personal and social services. Some uncertainty about the applicability of resource use and unit costs from 2002 to the current NHS context. Retrospective observational study, so by definition not reflecting all evidence in this area. Univariate analysis was used, so results subject to confounding. Some uncertainty about whether time horizon is sufficient to reflect all differences in costs and outcomes. Both local and National unit costs used, so some uncertainty regarding whether the local costs reflect national averages. Limited sensitivity analysis presented. Other:


Abbreviations: CEA: cost-effectiveness analysis; 95% CI: 95% confidence interval; CF: cystic fibrosis; EV1: Fixed expiratory volume in 1 second; ICER: incremental cost-effectiveness ratio; IV: Intravenous; NHS: National Health Service; NR: not reported; QALYs: quality-adjusted life years. (a) For studies where the time horizon is longer than the treatment duration, an assumption needs to be made about the continuation of the study effect. For example, does a difference in utility between groups during treatment continue beyond the end of treatment and if so for how long. (b) Directly applicable/Partially applicable/Not applicable. (c) Minor limitations/Potentially serious limitations/Very serious limitations.



Economic analysis: CCA Population: Total costs (mean per Mortality-3months: ICER (Intervention 2 versus Intervention 1):

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(health outcome: mortality, treatment failure, time to recovery )

Study design: RCT

Approach to analysis: within trial analysis of health outcomes and resource use. Unpaired t-test was used to compare costs in both arms.

Perspective: Italian health care provider

Follow-up: 3 months



Adult neuromuscular patients with respiratory tract infection requiring hospital admission


Mean age:

Intervention 1:46.7 years


Male:




Admission to hospital for inpatient treatment of respiratory tract infection


Treatment at home under the care of a Hospital-at-home service. The service was delivered primarily by a district nurse with follow-up from a pulmonologist and respiratory therapist.

patient):



Incremental (2−1): £7,395

(95% CI: NR; p<0.001)


2010 Euros (presented here as 2010 UK pounds(b))


Home visits by pulmonologist, district nurse and respiratory therapist.

Daily rental costs for mechanical cough assist and portable ventilator, antibiotic prescriptions and telephone calls.

Hospital stays


Intervention 2: 11.5 %

Incremental (2−1):- 3.3%

(95% CI: NR; p=0.42)

n/a


no sensitivity analysis reported

Data sources

Health outcomes: Within trial analysis with baseline data collected using clinical and functional measure. Data on mortality were collected 3 months. Quality-of-life weights: n/a. Cost sources: both local and national unit cost sources were used.

Comments

Source of funding: NR. Applicability and limitations: Cost-consequences analysis, so QALYs are not used as outcome. Some uncertainty about the applicability of resource use and unit costs from Italy in 2010 to the current NHS context. RCT-based analysis so from one study by definition therefore not reflecting all evidence in area. It is not clear whether the cost of hospitalisation is included for those patients in the hospital at home arm who failed treatment and required hospitalisation. Unit

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costs from both local and national sources so may not be completely reflective of national unit costs. No sensitivity analysis is reported.

Overall applicability(c): partially applicable Overall quality(d): potentially serious limitations

Abbreviations: CCA: cost–consequence analysis; 95% CI: 95% confidence interval; ICER: incremental cost-effectiveness ratio; NR: not reported; QALYs: quality-adjusted life years. (a) For studies where the time horizon is longer than the treatment duration, an assumption needs to be made about the continuation of the study effect. For example, does a difference in utility between groups during treatment continue beyond the end of treatment and if so for how long. (b) Converted using 2010 purchasing power parities.223 (c) Directly applicable/Partially applicable/Not applicable. (d) Minor limitations/Potentially serious limitations/Very serious limitations.

E.1.2 Early discharge

Study Goossens 2013118


Economic analysis: CUA (health outcome: QALYs). NB CEA also but not presented in this table.

Study design: RCT (Going Home under Early Assisted Discharge trial)- – associated clinical papers Utens 2012, Utens 2013 and Uten 2014300,302,303

Approach to analysis: Analysis of individual patient-level data. Unit costs applied. EQ-5D data analysed using multivariable analysis, adjusting for baseline score. Cost data analysed

Population:

Patients (40 years or older) admitted to one of the participating hospitals for a COPD exacerbation


Start age:



Male:




Continuation of inpatient

Total cost of initial admission plus follow-up (mean per patient):




(95% CI: -£977 to £719; p=NR)

Costs of initial admission:




(95% CI: -£246 to £131; p=NR)


2009 Euros (presented here as 2009 UK pounds(b))

QALYs (mean per patient):




(95% CI: -0.021 to 0.0095; p=NR)


£24,252 per QALY lost

95% CI: NR

Probability Intervention 2 cost saving:

61.2%

Probability Intervention cost-effective at

20K/30K threshold): 58%/55%(c)


Bootstrapping of cost and outcome data was used to address uncertainty.

SAs conducted included:

Using different unit cost per inpatient hospital day instead of micro-costing study estimate: from Dutch Manual for Costing Studies, using the most costly and the least costly hospital and the most costly and the least costly patient estimates.

Early supported discharge was cost saving all

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using linear repeated-measures model with correlated error terms. Intention to treat analysis with missing values handled using repeated measures model.

Perspective: Netherland health care perspective (societal also analysed but not presented here)

Follow-up(a): 3 months


hospital treatment (HOSP) for COPD exacerbation for 4 days, after an initial 3 days under usual hospital treatment


Early supported discharge (ESD) scheme (hospital-at-home) after an initial 3 days under usual hospital treatment involving treatment and supervision at home for the remaining 4 days by a community nurse who is generically trained (not specialist). The community nurse visited the patient once to three times on the day of discharge and the three following days. This care package is delivered by community-based home-care organisation which could support the patient in their daily activities (for example washing and dressing). The general practitioner was informed of the early discharge but the respiratory physician of the hospital kept the final


Hospital stay

Physician visits

Community nursing care

Hospital admissions

Emergency department visits

Visits/contact with: pulmonologist or other, specialist physicians, GP and other health care professionals

Number of ambulance rides

Medication use

SAs. The ICER ranged from £1,444 per QALY lost to £211,342 per QALY lost for all SAs. The probability that ESD was cost saving ranged from 50% to 99.8%. Using the inpatient hospital day cost from the Dutch Manual for Costing Studies (National unit cost) resulted in the best case scenario for ESD, resulting in an ICER of £211,342 per QALY lost and probability that ESD was cost saving of 99.8%.

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responsibility

Data sources

Health outcomes: Within RCT analysis. Clinical outcome data were collected from patients after 7 days (end of initial admission) and 3 months (initial follow-up). Quality-of-life assessment using EQ-5D took place at the end of follow-up (3 months) Quality-of-life weights: EQ-5D Dutch tariff (scores range from -0.329 (worst possible state) to 1 (perfect health)]. Cost sources: resource use data for hospital-at-home patients recorded using 4-day diary during initial admission and weekly diary during follow-up. Standard unit costs from the Dutch Manual for Costing Studies and the official list of drug prices were used as the source of unit costs. A micro-costing study was also conducted to determine the cost of an inpatient hospital day.

Comments

Source of funding: Institutional funding. Applicability and limitations: Some uncertainty regarding the applicability of resource use (2007-2011) and unit costs (2009) from the Netherlands. RCT-based analysis, so from one study by definition therefore not reflecting all evidence in area that compares early supported discharge versus inpatient admission. Micro-costing study was used to calculate the cost of inpatient bed day cost in the base case analysis, which does not reflect the national unit cost for inpatient hospital day. Some uncertainty about whether time horizon of 3 months is sufficient to capture all benefits and costs.

Overall applicability(d): Partially applicable Overall quality(e): Potentially serious limitations

Abbreviations: CEA: Cost-effectiveness analysis; 95% CI: 95% confidence interval; CUA: cost–utility analysis; EQ-5D: Euroqol 5 dimensions (scale: 0.0 [death] to 1.0 [full health], negative values mean worse than death); ESD: Early supported discharge; ICER: incremental cost-effectiveness ratio; NR: not reported; pa: probabilistic analysis; QALYs: quality-adjusted life years; SA: sensitivity analysis. (a) An assumption is made about the continuation of the intervention effect beyond the 4-day treatment period. (b) Converted using 2009 purchasing power parities.223 (c) Estimated from graph. (d) Directly applicable/Partially applicable/Not applicable. (e) Minor limitations/Potentially serious limitations/Very serious limitations.

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E.1.3 Both admission avoidance and early discharge

Study Bakerly 200923

Study details Population & interventions Costs Health outcomes

Cost effectiveness

Economic analysis: CC (health outcome: N/A )

Study design: matched case-control, with retrospective controls matched on age, sex and post code

Approach to analysis: Means and mean differences, with bias-corrected bootstrap analysis used to calculate 95% CIs around the mean estimates.

Perspective: UK NHS

Follow-up 12 months


Discounting: Costs: NR; Outcomes NR:

Population:

Patients admitted to a university hospital with acute exacerbation of COPD (AECOPD)


Mean age:



Male:

Intervention 1: 56%

Intervention 2: 55%


Usual inpatient care for AECOPD, where patients stayed in hospital for the whole length of the admission.


Care delivered by an acute COPD assessment service (ACAS), which provided an integrated care model. *





(95% CI: NR; p<0.001)


2007 UK pounds


Specialist nurse visits

Emergency department visits

Emergency home visits

Contacts with other health care professionals (GP, district nurse, occupational therapist)

Emergency ambulance transfers

Hospital admissions and length of stay

Outpatient clinic visits

N/A (3-month readmission rate was assumed equal)


N/A

95% CI: N/A

Probability Intervention 2 cost-effective (£20K/30K threshold): N/A


Bootstrapping was used to calculate 95% CI around the mean cost estimates.

Total costs:

Intervention 1:

95% CI: £2,126 to £2,407

Intervention 2:

95% CI: £1,521 to £1,802

Data sources

Health outcomes: N/A (3-month readmission rate was assumed equal). Quality-of-life weights: N/A. Cost sources: the unit costs were derived from national sources (NHS reference costs and PSSRU)

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Comments

Source of funding: Local, non-commercial funding (local respiratory research fund). Applicability and limitations: The model evaluated in the study is an integrated care model, with hospital at home representing one component of the model. Some uncertainty exists regarding the applicability of resource use and costs from 2007 to the current NHS context. QALYs were not used as an outcome measure as the study compares costs only. Observational, matched case control study with no adjustment for possible confounders other than the matching variables. So, so does not reflect all the evidence available for this comparison. One year follow-up; so may not capture the long-term consequences of the intervention. The study compares costs only and no health outcomes are considered. No sensitivity analysis is reported.

Overall applicability(b): partially applicable Overall quality (c): potentially serious limitations

* The ACAS team comprised 3 full-time specialist respiratory nurses and middle-grade physician (0.4 whole time equivalent) assessing AECOPD admissions daily. Suitable patients received the following interventions: early discharge (with support at home, available 7-days a week from 9:00 am to 5:00 pm.), patient’s education and clinic assessment 60 days from the index episode, where a clinical management plan is agreed and communicated to the patient’s GP. Patients’ could also refer themselves or be referred by their GP to the ACAS service (avoiding admissions) Abbreviations: CC: comparative costing; COPD: Chronic obstructive pulmonary disease; 95% CI: 95% confidence interval; ICER: incremental cost-effectiveness ratio; NR: not reported; QALYs: quality-adjusted life years. (a) For studies where the time horizon is longer than the treatment duration, an assumption needs to be made about the continuation of the study effect. For example, does a difference in utility between groups during treatment continue beyond the end of treatment and if so for how long. (b) Directly applicable/Partially applicable/Not applicable. (c) Minor limitations/Potentially serious limitations/Very serious limitations.

Study Patel 2008229


Economic analysis: CUA (health outcome: QALYs)

Study design: Within –trial analysis (RCT)

Approach to analysis: Analysis of individual level data for resource use. Unit costs applied.

Perspective: Not reported (appears to be Swedish healthcare system)

Follow-up: 12 months

Population:

Patients seeking care for deterioration of chronic heart failure identified within 24-48 hours after admission from three medical facilities: ED, Heart failure outpatient clinic and a medical ward.


Start age:

Intervention 1: 78 years (SD=8)




Incremental (2−1):- £1,960

(95% CI: NR; p=0.05)


Assumed to be 2006 Euros[(presented here as 2006 UK pounds(a))]


Specialist nurses’ time


EQ-5D visual analogue scale:




(95% CI: NR; p=NR)

SG utilities:




(95% CI: NR; p=NR)


2 dominates 1


SA using last value carried forward for people lost to follow-up:

EQ-5D QALYs for the intervention 1 group 0.5

SG QALYs for the intervention 1 group: 0.75

QALYs calculation using the following alternative assumptions (Not clear which one is base case):

Any change in HRQoL between two measurement points occurred immediately after the first measurement point

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Study Patel 2008229



Intervention 2: 77 years (SD=10)

Male:

Intervention 1: 83%

Intervention 2: 46%


Hospital admission/conventional care (CC)


Home care under the direction of a specialist nurse (HC)

(including home visits, administration, transportation)

Physicians’ time (including consultations, prescriptions, referrals)

Laboratory tests

IV diuretics

Emergency visits

Hospitalisations due to HF

Telephone contacts with HF clinic

Visits to HF clinic

Any change in HRQoL occurred immediately before the second measurement point

Any change occurred in HRQoL exactly half-way between the two measurement points

No differences were observed

Costs:

Difference in the cost of initial intervention was significant (p<0.001)

Difference in total costs was significant (p=0.04)

Differences in total costs including HF clinic was significant (p=0.05)

Outcomes:

No significant difference in QALYs gained

Data sources

Health outcomes: patients completed four follow-up sets of questionnaires at 1, 4, 8 and 12 months. Patients’ clinical status was documented and information about clinical events was elicited through patient interviews and complemented by the patients’ medical records. Quality-of-life weights: EQ-5D visual analogue scale values rather than tariff utilities were used. SG utilities were also measured. Cost sources: resource use data was recorded using patient interviews and patients’ medical records. Costs were based on the hospital’s financial department records.

Comments

Source of funding: NR. Applicability and limitations: Some uncertainty about the applicability of resource use and costs (2004-2006) from Sweden. QALYs are calculated using the VAS values. RCT-based analysis so from one study by definition therefore not reflecting all evidence in area. Local costs are used; some uncertainty as to whether these reflect national costs. Some uncertainty regarding whether time horizon is sufficient (12 months follow-up). Limited number of deterministic sensitivity analyses presented.

Overall applicability(b): Partially applicable Overall quality(c): potentially serious limitations

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Abbreviations: 95% CI: 95% confidence interval; CUA: cost–utility analysis; ED: Emergency department; EQ-5D: Euroqol 5 dimensions (scale: 0.0 [death] to 1.0 [full health], negative values mean worse than death); HF: heart failure; ICER: incremental cost-effectiveness ratio; NR: not reported; pa: probabilistic analysis; QALYs: quality-adjusted life years; SA: sensitivity analysis; SG: Standard gamble; VAS: Visual analogue scale. (a) Converted using 2006 purchasing power parities.223 (b) Directly applicable/Partially applicable/Not applicable. (c) Minor limitations/Potentially serious limitations/Very serious limitations.

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Study Puig-Junoy 2007235


Cost effectiveness

Economic analysis: CC (health outcome: n/a)

Study design: RCT (linked to Hernandez 2003141 (see clinical review)

Approach to analysis: Resource use data collected from patient medical records and using resource use instruments. Cost data collected within-trial were analysed using multiple regression analysis with log transformation and bias correction

Perspective: Spanish public health insurer (third party payer)

Follow-up 8 weeks


Population:

Patients presenting to ED with acute exacerbation of COPD.


Mean age: 70.8 years

Male:97.8%


Conventional care in hospital (CC)


Nurse-led hospital-at-home involving up to 5 visits from specialist respiratory nurse and phone consultation whenever needed. Patients were followed up for 8 weeks then discharged.

Total costs (mean per patient, adjusted):




(95% CI: NR; p< 0.01)

For patients with low severity COPD:


(95% CI: NR; p=NR)

For patients with moderate severity COPD:


(95% CI: NR; p=NR)

For patients with severe COPD:


(95% CI: NR; p=NR)


2000 Euros (presented here as 2000 UK pounds(a))]


Hospital stays (initial hospitalisation and readmission), ED visits, Outpatient visits

Primary care physician visits, Visits for social support, Nurse visits at home, Ambulatory treatment prescriptions, Phone calls, Transportation services

n/a (CC) ICER (Intervention 2 versus Intervention 1):

NA



Data sources

Health outcomes: n/a (data on health outcomes from this RCT were reported in another paper (Hernandez 2003141); however, the analysis set for the cost analysis is

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different from that in Hernandez 2003141. Quality-of-life weights: n/a Cost sources: Labour cost market prices including value added taxes and overheads were used to calculate costs of nurse visits at home, phone calls and transportation services. Hospital unit costs per in-hospital stay and visits were calculated as average observed tariffs for COPD patients in a public insurance company covering the civil servants of the City Council of Barcelona (PAMEM).

Comments

Source of funding: NR. Applicability and limitations: Uncertainty regarding the applicability of resource use (1999-2000) and unit costs (2000) from Spain to the UK NHS context. Comparative cost analysis, assuming equivalent outcomes, so QALYs are not used as an outcome measure. Short time horizon (8 weeks) which might not capture all the differences in costs. Within-trial comparative costing analysis so does not reflect all the evidence in this area. The authors assumed equivalent health outcomes despite a previous publication from the same trial reporting favourable outcomes for hospital-at-home. Uncertainty was not appropriately addressed and no sensitivity analysis undertaken.


Abbreviations: 95% CI: 95% confidence interval; CC: comparative costing; COPD: chronic obstructive pulmonary disease; CUA: cost–utility analysis; ED: emergency department; ICER: incremental cost-effectiveness ratio; NR: not reported; QALYs: quality-adjusted life years. (a) Converted using 2000 purchasing power parities.223 (b) Directly applicable/Partially applicable/Not applicable. (c) Minor limitations/Potentially serious limitations/Very serious limitations.

Study Teuffel 2011288


Economic analysis: CUA (health outcome: quality-adjusted febrile neutropenia episodes [QAFNE] )

Study design: Probabilistic decision analytic model


The analysis was based on a decision-tree model

Perspective:

Time horizon(a): One FN episode (maximum follow-up of 30 days)

Population:

Adult cancer patients low risk FN receiving antibiotic treatment

Cohort settings: hypothetical cohort

Start age: NR

Male: NR

Intervention 1: treatment in hospital with intravenous antibiotics (combination of piperacillin and tazobactam, plus tobramycin) (HospIV)






For incremental analysis see cost effectiveness column


2009 Canadian dollars (presented here as 2009 UK

Quality-adjusted FN episodes (QAFNEs):





For incremental analysis see cost effectiveness column

ICER:

Int Inc cost Inc QAFNE ICER

1 Dominated

2 Dominated

3 £387 0.07 £5,534

4 Baseline reference

Early discharge and with hospital intravenous treatment were dominated, as they were more expensive and less effective than another strategy.

At a threshold of ~ £2000 per QAFNE (calculated to be corresponding to a cost-effectiveness threshold of £27,000 per QALY:

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Intervention 2:

Early discharge after 48 hours in-patient observation with IV antibiotics (combination of piperacillin and tazobactam, plus tobramycin), followed by oral out-patient treatment (EarlyDC)

Intervention 3:

Entire out-patient management with intravenous antibiotics (combination of piperacillin and tazobactam, plus tobramycin) (HomeIV)

Intervention 4:

Out-patient management with oral antibiotics (ciprofloxacin plus the combination of amoxicillin and clavulanate)(HomePO)

Treatment duration was 6 days for all strategies

pounds(b))]


Hospitalisations, initial consultation, out-patient visits, home nursing, and medications.

Intervention 4 (HomePO) was cost-effective in 54% of simulations, while intervention 3 (HomeIV) was cost-effective in 38% of simulations. Intervention 2 (EarlyDC) was cost-effective in 8% of simulations and intervention 1 was cost-effective in less than 1% of simulations.


PSA was used. The results were sensitive to variations in the costs of in-patient stay, out-patient visits, and home nurse visits. The duration of treatment and some utility assumptions were also key inputs. In some scenarios, home intravenous treatment was the preferred strategy, but the in-patient treatments were never cost-effective.

Data sources

Health outcomes: Systematic review of effectiveness evidence was conducted as part of the study and only RCTs were included. Further data were from observational studies. Quality-of-life weights: preference elicitation study conducted with 77 adult cancer patients receiving treatment in hospital using VAS and the values transformed into SG utilities using power function. Cost sources: The resource quantities were mostly from published studies. Unit costs were from the Ontario Health Insurance Schedule of Benefits and Fees, the local finance offices, and the Department of Pharmacy at Princess Margaret Hospital.

Comments

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Source of funding: Institutional funding. Applicability and limitations: Some uncertainty regarding the applicability of resource use and unit costs from Canada (2009). The outcome used is not QALYs, but rather a quality adjusted FN episode. The short time horizon used (30 days) might not reflect all differences between strategies in terms of costs and outcomes. Some local costs were used to calculate the costs of hospital fees/charges and home care nurse visits. The baseline probability of health care-associated infection was based on data from observational studies. It was not reported how these studies were identified. The cost-effectiveness threshold used in the PSA was arbitrary and may not have a meaningful interpretation.

Overall applicability(c): Partially applicable Overall quality(d): Potentially serious limitations

Abbreviations: CCA: cost–consequence analysis; CEA: cost-effectiveness analysis; 95% CI: 95% confidence interval; CUA: cost–utility analysis; da: deterministic analysis; EQ-5D: Euroqol 5 dimensions (scale: 0.0 [death] to 1.0 [full health], negative values mean worse than death); ICER: incremental cost-effectiveness ratio; IV: intravenous; NR: not reported; pa: probabilistic analysis; QALYs: quality-adjusted life year; SA: sensitivity analysis; SG: standard gamble; VAS: visual analogue scale. (a) It is not clear if an assumption of continuous treatment effect beyond initial treatment duration is used in the analysis. (b) Converted using 2009 purchasing power parities.223 (c) Directly applicable/Partially applicable/Not applicable. (d) Minor limitations/Potentially serious limitations/Very serious limitations.

E.2 Step-up/Step-down

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Study Monitor 2015204


Cost effectiveness

Economic analysis: CC

Study design: Discrete event simulation model

Approach to analysis: Simulation model of individual patients flowing through a local health economy based on input data including patient characteristics, system capacity and referral pattern. Comparison of capacity used with and without a scheme with unit costs applied, broken down into fixed, semi-fixed and variable.

Perspective: UK NHS (societal also included)

Time horizon(a): 5 years


Population:

Simulated hospital inpatients.

Cohort settings:

n/a

Intervention 1:

Usual hospital care.

Intervention 2:

Short-term treatment to patients who are not suffering a hyper-acute episode in a community hospital setting. Patients referred by GP or ambulance, receiving treatment within two hours from a multidisciplinary team led by a consultant, seven days a week.

Total cumulative costs over five years:

Intervention 1: NR

Intervention 2: NR

Incremental (2−1): £1m

(95% CI: NR; p=NR)

Cost of patient spell in fifth year of the scheme:




(95% CI: NR; p=NR)

Currency & cost year: UK pounds; year NR


Setup, fixed, semi-fixed and variable costs.

N/A Results show the scheme will not break even over five years. However, in the fifth year, uptake of the service is high enough to see it be cost saving.


Estimated that a similar scheme would need to cost around £550 to £600 per patient intervention to be cost saving compared to treating patients in the acute setting.

Data sources

Health outcomes: NA Quality-of-life weights: NA Cost sources: Bottom-up costs reviewed through data requests to providers running similar schemes and used to build costs models identifying the workforce, variable and setup costs of schemes. Identified key factors that influence cost structure of schemes and then test with other providers and clinicians. Acute pathway costs from a combination of patient-level information and costing systems, cost data and ward staffing model.

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Cost effectiveness

Comments

Source of funding: NHS England Applicability and limitations: Not enough detail around methodology and modelled cohort. Costs not explicitly reported as per patient value. Cost year not reported for comparison. Full breakdown of cost inputs and outputs not reported.

Overall applicability(b): Partially applicable Overall quality(c): Potentially serious limitations

Abbreviations: CC: Comparative costing analysis; 95% CI: 95% confidence interval; CUA: cost–utility analysis; EQ-5D: EuroQol 5 dimensions (scale: 0.0 [death] to 1.0 [full health], negative values mean worse than death);; ICER: incremental cost-effectiveness ratio; NR: not reported; pa: probabilistic analysis; QALYs: quality-adjusted life years; SA: sensitivity analysis. (a) One year modelling with extrapolation for further 4 years. (b) Directly applicable/Partially applicable/Not applicable. (c) Minor limitations/Potentially serious limitations/Very serious limitations.

Study O’Reilly 2008220


Economic analysis: CUA (health outcome: QALYs )

Study design: RCT

Approach to analysis: Within-trial analysis of individual patient level cost and outcome data. Resource use data collected from hospital patient administration system and via questionnaires. Data collected from patient questionnaires were corroborated against a community database and agreement ascertained. Missing values were

Population:

Elderly patients requiring rehabilitation following hospital admission with an acute illness


Mean age: NR

Male: NR


General hospital care


Community hospital care




Incremental (2−1): £720

(95% CI: -£523 to £1,964; p=NR)


2001-2002 UK pounds


Hospital admissions, visits to emergency department, day hospitals, day centres, general practitioners, outpatient visits, out-of-hours services, home visits





(95% CI: -0.028 to 0.123; p=0.214)


£16,324 per QALY gained (pa)

95% CI: NR

Probability Intervention 2 cost-effective (£10k/30K threshold): 47%/50%


Bootstrapping was used to assess the impact of uncertainty.

Costs of initial hospital admission, subsequent readmission and institutional care costs were explored in sensitivity analyses which gave similar results to the base case analysis.

A threshold analysis showed that when the per diem cost of the community hospital is reduced by over 30%, the mean cost per patient treated at a community hospital

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imputed using the mean value for the treatment group.

Perspective: UK NHS and PSS

Follow-up: 6 months



by health or social care staff, residential and nursing homes, equipment and adaptation.

becomes lower than at a general hospital.

Data sources

Health outcomes: Within-trial analysis with EQ-5D data collected at baseline, at one week after discharge. And 3 and 6 months after randomisation. Quality-of-life weights: EQ-5D UK tariff was used to calculate QALYs. Cost sources: Resource use data were collected one week after discharge, and 3 and 6 months following randomisation using an interviewer-completed questionnaire administered to the patients and their carers. Hospital inpatient use data were obtained from the hospital patient administration system. Both local and national sources including PSSRU and NHS Reference Costs and NHS Purchasing and Supply Agency were used to calculate costs. Cost of hospital stay was based on data from the hospitals’ finance departments and included both direct and indirect costs. Costs were calculated net of patients’ contribution, where this occurred (for example in case of some community services such as chiropody and home care).

Comments

Source of funding: Government and charity funding. Applicability and limitations: Some uncertainty regarding the applicability of resource use and unit costs from 2001-2002 to current NHS context. Within-trial analysis so does not reflect all the evidence available for this comparison between care at a community hospital and at a district general hospital setting. The short time horizon (6 months) may not reflect all potential differences in costs and outcomes. An assumption was also made about the persistence of effect up to 1 year, which was not supported by evidence. Both local and national unit costs were used for the analysis. It is not clear whether the local unit costs used for some of the community care resources would be representative of national unit costs. Additionally, only a limited number of assumptions was tested in sensitivity analysis.

Overall applicability(b): partially applicable Overall quality(c): minor limitations

Abbreviations: 95% CI: 95% confidence interval; CUA: cost–utility analysis; EQ-5D: Euroqol 5 dimensions (scale: 0.0 [death] to 1.0 [full health], negative values mean worse than death); ICER: incremental cost-effectiveness ratio; NR: not reported; pa: probabilistic analysis; QALYs: quality-adjusted life years. (a) For studies where the time horizon is longer than the treatment duration, an assumption needs to be made about the continuation of the study effect. For example, does a difference in utility between groups during treatment continue beyond the end of treatment and if so for how long. (b) Directly applicable/Partially applicable/Not applicable. (c) Minor limitations/Potentially serious limitations/Very serious limitations.

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E.3 Virtual wards









Population:


Cohort settings:

n/a

Intervention 1:


Intervention 2:

24 hour remote triaging, advice and treatment to patients through video link. Aim to prevent unwell patients from attending hospital. Scheme provided by senior nurses to primarily frail elderly living in nursing homes.


Intervention 1: NR

Intervention 2: NR


(95% CI: NR; p=NR)





(95% CI: NR; p=NR)






Estimated that a similar scheme would need to cost around £4,000 to £4,300 per patient intervention to be cost saving compared to treating patients in the acute setting.

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Data sources


Comments



Abbreviations: CC: Comparative costing analysis; 95% CI: 95% confidence interval; CUA: cost–utility analysis; EQ-5D: Euroqol 5 dimensions (scale: 0.0 [death] to 1.0 [full health], negative values mean worse than death);; ICER: incremental cost-effectiveness ratio; NR: not reported; pa: probabilistic analysis; QALYs: quality-adjusted life years; SA: sensitivity analysis. (a) One year modelling with extrapolation for further 4 years. (b) Directly applicable/Partially applicable/Not applicable. (c) Minor limitations/Potentially serious limitations/Very serious limitations.

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E.4 Rapid response



Cost effectiveness






Discounting: n/a

Population:


Cohort settings:

n/a

Intervention 1:


Intervention 2:

Rapid response and early supported discharge scheme. Scheme ran by a single consultant-led multidisciplinary team, seven days a week within patients own home. Scheme targets patients identified in acute inpatient wards, often recovering from an operation.



(95% CI: NR; p=NR)





(95% CI: NR; p=NR)






Estimated that a similar scheme would need to cost around £350 per patient intervention to be cost saving compared to treating patients in the acute setting.

Data sources


Comments



Abbreviations: CC: Comparative costing analysis; 95% CI: 95% confidence interval; n/a: not applicable; NR: not reported; (a) One year modelling with extrapolation for further 4 years. (b) Directly applicable/Partially applicable/Not applicable. (c) Minor limitations/Potentially serious limitations/Very serious limitations.

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Appendix F: GRADE tables

Table 12: Clinical evidence profiles- Alternatives compared with hospital care

Quality assessment No of patients Effect

Quality Importance

No of

studies Design

Risk of

bias Inconsistency Indirectness Imprecision

Other

considerations Alternatives

Hospital

care

Relative

(95% CI) Absolute

Mortality - early discharge - Hospital at home led by primary care

5 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness

very serious1 None 17/309

(5.5%)

6.9% RR 0.9 (0.47

to 1.71)

7 fewer per 1000

(from 37 fewer to 49

more)

LOW

CRITICAL

Length of stay (initial inpatient days) - early discharge - Hospital at home led by primary care

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness

serious1 None 121 101 - MD 2.44 lower (3.34

to 1.54 lower)

MODERAT

E

CRITICAL

Admissions - early discharge - Hospital at home led by primary care

6 randomised

trials

serious2 no serious

inconsistency

no serious

indirectness

serious1 None 96/317

(30.3%)

36.7% RR 0.92

(0.73 to

1.15)

29 fewer per 1000


more)

LOW

IMPORTAN

T

Presentations to ED - early discharge - Hospital at home led by primary care

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness


(9.1%)

20.8% RR 0.44

(0.22 to

0.86)

116 fewer per 1000


fewer)

MODERAT

E

IMPORTAN

T

Quality of life (high score is good) - early discharge - HAH led by primary care (SGRQ; change score; reversed)

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2 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness

serious1 None 151 131 - MD 3.49 higher (0.38

lower to 7.36 higher)

MODERAT

E

CRITICAL

Quality of life (higher values better QoL) - early discharge - HAH led by primary care (COOP chart; change score; reversed)

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness

serious1 None 38 37 - SMD 0.17 higher

(0.29 lower to 0.62

higher)

MODERAT

E

CRITICAL

Patient Satisfaction (continuous-higher values more satisfied) - early discharge - Hospital at home primary care

2 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness

no serious

imprecision

None 150 135 - SMD 0.25 higher

(0.01 to 0.48 higher)

HIGH

CRITICAL

Patient satisfaction (dichotomous) - early discharge - Hospital at home led by Primary care

1 randomised

trials

serious2 no serious

inconsistency

no serious

indirectness

no serious

imprecision

None 25/27

(92.6%)

88.9% RR 1.04

(0.88 to

1.24)

36 more per 1000

(from 107 fewer to

213 more)

MODERAT

E

CRITICAL

Carer satisfaction (dichotomous) - early discharge - Hospital at home led by primary care

1 randomised

trials

serious2 no serious

inconsistency

no serious

indirectness

no serious

imprecision

None 18/20

(90%)

92.9% RR 0.97

(0.79 to

1.19)

28 fewer per 1000

(from 195 fewer to

177 more)

MODERAT

E

CRITICAL

Quality of life (high score is good) - early discharge - HAH led by primary care (EQ-5D; change score)

1 randomised

trials

serious2 no serious

inconsistency

no serious

indirectness



LOW

CRITICAL

Mortality - early discharge - Hospital at home led by secondary care

1 randomised

trials

very

serious2

no serious

inconsistency

no serious

indirectness

very serious1 None 2/13 (15.4%)

11.1% RR 1.38

(0.22 to

8.59)

42more per 1000


more)

VERY LOW

CRITICAL

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Re-Admissions early discharge- Hospital at home led by secondary care

1 randomised

trials

serious2 no serious

inconsistency

no serious

indirectness

very serious1 None 1/42 12.7% RR 0.50

(0.05 to

5.31)

64 fewer per 1000

(121 fewer to 547

more)

VERY LOW

IMPORTAN

T

Mortality - early discharge - Hospital at home led by both primary and secondary care

4 randomised

trials

serious2 no serious

inconsistency

no serious

indirectness


(11.8%)

14% RR 1.02

(0.72 to

1.44)

3 more per 1000


more)

VERY LOW

CRITICAL

Readmissions (30 days) - early discharge - Hospital at home led by both primary and secondary care

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness


(21%)

12.7% RR 1.66

(0.97 to

2.83)

84 more per 1000


more)

MODERAT

E

IMPORTAN

T

Admissions - early discharge - Hospital at home led by both primary and secondary care

5 randomised

trials

serious2 no serious

inconsistency

no serious

indirectness

no serious

imprecision

None 99/448

(22.1%)

20% RR 0.94

(0.74 to 1.2)

12 fewer per 1000


more)

MODERAT

E

IMPORTAN

T

Length of stay (days in treatment) - early discharge - Hospital at led by primary and secondary care (Better indicated by lower values)

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness


to 4.39 higher)

MODERAT

E

CRITICAL

Carer satisfaction (dichotomous) - early discharge - Hospital at home led by both primary and secondary care

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness

serious1 None 46/69

(66.7%)

41.4% RR 1.61

(1.14 to

2.28)

253 more per 1000

(from 58 more to 530

more)

MODERAT

E

CRITICAL

Patient Satisfaction (continuous-higher values more satisfied) - early discharge - Hospital at home led by primary and secondary care

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1 randomised

trials

serious2 no serious

inconsistency

no serious

indirectness

no serious

imprecision

None 140 141 - SMD 0.25 higher

(0.01 to 0.48 higher)

MODERAT

E

CRITICAL

Quality of life (high score is good) - early discharge - HAH led by primary and secondary care (final score; SF-36; physical)

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness

no serious

imprecision

None 121 120 - MD 0.4 higher (2.2

lower to 3 higher)

HIGH

CRITICAL

Patient satisfaction (dichotomous) - early discharge - Hospital at home led by both primary and secondary care

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness


(83%)

72.5% RR 1.15 (1

to 1.32)

109 more per 1000

(from 0 more to 232

more)

MODERAT

E

CRITICAL

Quality of life (high score is good) - early discharge - HAH led by primary and secondary care (final score; SF-36; mental)

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness

no serious

imprecision

None 121 120 - MD 1.3 higher (1.55


HIGH

CRITICAL

Mortality - early discharge - Step up/down care

3 randomised

trials

serious2 no serious

inconsistency

no serious

indirectness


(22.9%)

21.5% RR 0.88

(0.71 to 1.1)

26 fewer per 1000

(from 62 more to 22

more)

LOW

CRITICAL

Length of stay (initial inpatient days) - early discharge - Step up/down care (Better indicated by lower values)

2 randomised

trials

serious risk

of bias2

very serious3 no serious

indirectness


to 5.95 higher)

VERY LOW

CRITICAL

Readmissions - early discharge - Step up/down care

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness

serious1 None 14/72

(19.4%)

35.7% RR 0.54

(0.31 to

0.96)

164 fewer per 1000


fewer)

MODERAT

E

IMPORTAN

T

Mortality- early discharge- virtual wards

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1 randomised

trials

serious2 no serious

inconsistency

no serious

indirectness

serious1 None 3/29

(10.3%)

14.3% RR 0.72

(0.18 to

2.95)

40 fewer per 1000

(from 117 more to

279 more)

VERY LOW

CRITICAL

Quality of life -early discharge- virtual wards (EQ-5D summary index; change score)

1 randomised

trials

serious2 no serious

inconsistency

no serious

indirectness

no serious

imprecision

None 29 28 - MD 0.00 higher (0.15


MODERAT

E

CRITICAL

Mortality - Admission avoidance - Hospital at home led by primary care

2 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness


(17.4%)

30.9% RR 0.82

(0.53 to

1.29)

56 fewer per 1000


more)

MODERAT

E

CRITICAL

Admissions(>30 days) - Admission avoidance - Hospital at home led by primary care

2 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness


(18.4%)

10.3% RR 1.29

(0.73 to

2.29)

30 more per 1000


more)

LOW

IMPORTAN

T

Adverse events - Admission avoidance - Hospital at home led by primary care

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness


(41.7%)

32% RR 1.3 (0.62

to 2.73)

96 more per 1000

(from 122 fewer to

554 more)

LOW

CRITICAL

Days to discharge (hazard ratio) - Admission avoidance - Hospital at Home Primary Care (Hazard Ratio)

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness


(0%)

0% HR 0.95

(0.71 to

1.27)

-

LOW

IMPORTAN

T

Patient satisfaction (dichotomous) - Admission avoidance - Hospital at home led by Primary care

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness

no serious

imprecision

None 87/91

(95.6%)

98.9% RR 0.97

(0.92 to

1.02)

30 fewer per 1000


more)

HIGH

CRITICAL

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Readmissions (< 30 days) - Admission avoidance - Hospital at home led by primary care

2 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness

no serious

imprecision

None 15/145 10.3% RR 4.68

(1.53 to

14.31)

114 more per 1000

(from 16 more to 413

more)

HIGH

IMPORTAN

T

Quality of life (high score is good) - Admission avoidance - HAH led by primary care (final score; SF-12; mental)

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness

very serious1 None 24 25 - MD 0.6 lower (5.46


LOW

CRITICAL

Quality of life (high score is good) - Admission avoidance - HAH led by primary care (final score; SF-12; physical)

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness



MODERAT

E

CRITICAL

Mortality - Admission avoidance - Hospital at home led by secondary care

4 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness


(12.9%)

15% RR 0.8 (0.47

to 1.35)

30 fewer per 1000


more)

LOW

CRITICAL

Admissions(>30 days) - Admission avoidance - Hospital at home led by secondary care

3 randomised

trials

serious2 no serious

inconsistency

no serious

indirectness


(31.7%)

50% RR 0.56

(0.42 to

0.75)

220 fewer per 1000

(from 125 fewer to

290 fewer)

LOW

IMPORTAN

T

Length of stay (days in treatment) - Admission avoidance - Hospital at home led by secondary care (Better indicated by lower values)

2 randomised

trials

serious2 serious4 no serious

indirectness

no serious

imprecision

None 85 87 - MD 4.69 higher (2.86

to 6.52 higher)

LOW

IMPORTAN

T

Quality of life (high score is good) - Admission avoidance - HAH led by secondary care (change score; SF-36; mental)

1 randomised

trials

serious2 no serious

inconsistency

no serious

indirectness



LOW

CRITICAL

Emergen

cy and

acute m

edical care

Ch

apte

r 12

Altern

atives to h

osp

ital care 1

73

Patient satisfaction (dichotomous) - Admission avoidance - Hospital at home led by secondary care

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness

no serious

imprecision

None 49/52

(94.2%)

88.5% RR 1.07

(0.95 to 1.2)

62 more per 1000


more)

HIGH

CRITICAL

Quality of life (high score is good) - Admission avoidance - HAH led by secondary care (NHP, change score; reversed)

2 randomised

trials

no serious

risk of bias

serious5 no serious

indirectness

no serious

imprecision

None 100 105 - MD 1.13 higher (0.29

to 1.97 higher)

MODERAT

E

CRITICAL

Quality of life (high score is good) - Admission avoidance - HAH led by secondary care (change score; SF-36; physical)

1 randomised

trials

serious2 no serious

inconsistency

no serious

indirectness



LOW

CRITICAL

Adverse events - Admission avoidance - Hospital at home led by both primary and secondary care

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness


(11.8%)

16.3% RR 0.72

(0.27 to

1.93)

46 fewer per 1000

(from 119 fewer to

152 more)

LOW

CRITICAL

Admissions(>30 days) - Admission avoidance - Hospital at home led by both primary and secondary care

2 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness


(29.1%)

22.1% RR 1.14

(0.74 to

1.74)

31 more per 1000


more)

LOW

IMPORTAN

T

Mortality - Admission avoidance - Hospital at home led by both primary and secondary care

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness


(9%)

8% RR 1.12

(0.36 to

3.47)

10 more per 1000


more)

LOW

CRITICAL

Patient Satisfaction (continuous-higher score is good) - Admission avoidance - Hospital at home led by primary and secondary care (reversed scale)

1 randomised no serious no serious no serious very serious1 None 40 20 - SMD 1.98 higher CRITICAL

Emergen

cy and

acute m

edical care

Ch

apte

r 12

Altern

atives to h

osp

ital care 1

74

trials risk of bias inconsistency indirectness (1.33 to 2.64 higher) LOW

Carer satisfaction (continuous) - Admission avoidance - Hospital at home led by primary and secondary care

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness

no serious

imprecision

None 28 13 - SMD 1.55 higher (0.8

to 2.29 higher)

HIGH

CRITICAL

Quality of life (high score is good) - Admission avoidance - HAH led by primary and secondary care (SGRQ; change score; reversed)

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness



MODERAT

E

CRITICAL

Length of stay (initial inpatient days) - Admission avoidance - Step up/down care (Better indicated by lower values)

1 randomised

trials

serious2 no serious

inconsistency

no serious

indirectness



LOW

IMPORTAN

T

Mortality - Admission avoidance - Step up/down care

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness

serious1 None 8/78

(10.3%)

20.8% RR 0.49

(0.22 to

1.09)

106 fewer per 1000


more)

MODERAT

E

CRITICAL

Mortality - Admission avoidance - Virtual wards

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness


(4.2%)

4.9% RR 0.85

(0.56 to

1.28)

7 fewer per 1000


more)

LOW

CRITICAL

Readmissions (30 days) - Admission avoidance - Virtual wards

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness

no serious

imprecision

None 182/961

(18.9%)

21.3% RR 0.89

(0.74 to

1.06)

23 fewer per 1000


more)

HIGH

IMPORTAN

T

Presentations to ED - Admission avoidance - Virtual wards

Emergen

cy and

acute m

edical care

Ch

apte

r 12

Altern

atives to h

osp

ital care 1

75

1 randomised

trials

no serious

risk of bias

no serious

inconsistency

no serious

indirectness

no serious

imprecision

None 270/961

(28.1%)

29.6% RR 0.95

(0.82 to

1.09)

15 fewer per 1000


more)

HIGH

IMPORTAN

T

1 Downgraded by 1 increment if the confidence interval crossed 1 MID point, and downgraded by 2 increments if the confidence interval crossed 2 MID points. 2 Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias. 3 Downgraded by 1 or 2 increments because heterogeneity, I2=92%, unexplained by sub-group analysis. 4 Downgraded by 1 or 2 increments because heterogeneity, I2=88%, unexplained by sub-group analysis. 5 Downgraded by 1 or 2 increments because heterogeneity, I2=50%, unexplained by sub-group analysis.



Appendix G: Excluded clinical studies

Table 13: Studies excluded from the clinical review

Reference Reason for exclusion

Abernethy 20132 Data presented ‘per patient’ and not overall

Abou el senoun 2014 3 Incorrect population and intervention. Planned home versus hospital management for women with preterm pre-labour rupture of membranes

Adib-hajbaghery 2013 4 Incorrect intervention. Effect of post-discharge follow-up on re-admission of patients with heart failure

Adler 19785 Not relevant: patients following elective surgery

Aimonino20009 Conference abstract; later published as Ricauda 2004240

Aimonino 20018 Patients not treated for acute medical emergency (advanced dementia patients)

Alder 197810 Incorrect population- Patients following elective surgery (hernia and varicose veins)

Allen 199911 Not RCT; description of a website

Anderson 2000A12 Included in community rehab review

Anderson 2002B13 Not RCT; Systematic review

Anderson 2002A14 No clinical outcomes; Costs only

Andrei 201115 Abstract

Anonymous 1982B1 Not relevant comparison

Armstrong 2008B17 Not RCT; Retrospective single arm study

Askim 200918 conference abstract

Aujesky 201119 RCT but no community care (self- administered injections)

Avlund 200220 Incorrect intervention. comprehensive geriatric assessment with follow-up by interdisciplinary geriatric team after discharge from hospital compared to existing discharge procedures

Bajwah 201522 Not relevant intervention. Palliative care for patients with advanced fibrotic lung disease. Study to be considered for community palliative review

Bai 201321 Not RCT; systematic review

Bakken 201224 No RCT; not relevant

Balaban 200825 Incorrect intervention. The study evaluated a discharge transfer intervention designed to improve communication between inpatient and outpatient care teams.

Barnes 200326 Not RCT; review

Beech 200427 Not RCT; service evaluation

Bernhaut 200228 Not RCT, service evaluation

Bethell 199029 Not substitute for usual care; control group received no intervention, only advice what exercises they could do by themselves

Beynon 200930 Not RCT; literature review

Biese 201431 Incorrect intervention-post-discharge telephone call follow-up by a nurse among older adults discharged home from the emergency department

Blackburn 200032 Not RCT; not relevant; costs only




Blair 201133 Not RCT; systematic review

Board 200034 Not relevant; costs only

Booth 200435 Not relevant; patients following bypass surgery

Boston 200136 Not RCT; prospective non-randomised comparative study

Boter 2004 37

Incorrect intervention. Study to be considered in the community nursing review.

Bowman 199839 Not RCT; review

Brooks 200240 Not RCT; retrospective case study

Brooks 200341 Not RCT; retrospective documentary analysis

Brunner 200842 Not RCT; other experimental design

Bryan 201043 Not RCT; literature review

Buus 201344 Protocol only; no study data

Campbell 200145 No clinical outcomes; costs only

Caplan 200648 Included in community rehab review

Caplan 201249 Not RCT; systematic review

Caplan 200450 Comparison is not hospital-based care

Carroll 200551 Not RCT; review

Cassel 201052 Not RCT; review

Chan 201153 Not RCT; Cochrane review, but NO included studies as none met the criteria

Chan 201354 Not RCT; Cochrane review, but NO included studies as none met the criteria

Chappell 199355 Not relevant; retrospective cost analysis

Chard 200656 Not RCT; review

Chen 2012A57 Not relevant; costs associated with acquired brain injury

Chumbler 201558 Not relevant intervention -multifaceted stroke tele-rehabilitation intervention on falls-related self-efficacy and satisfaction with care. Study to be considered in the community rehab review

Coast 59 Not relevant; majority of patients with trauma and elective surgery

Cobelli 199660 Not RCT; review

Coburn 198961 Not RCT; quasi-experimental; cost

Cohen 199462 Not RCT; review

Colprim 201264 Not RCT; quasi-experimental study

Colprim 201463 Not RCT; prospective cohort study

Conley 201665 Systematic review- screened for relevant references

Cowie 201469 Not RCT; economic analysis

Craig 201470 Not RCT; review

Crawford-Faucher 201071 Not RCT; systematic review - screened for relevant references

Crotty 200275 RCT but not relevant as trauma patients only (hip fracture)

Crotty 200073 Not RCT; audit of trauma patients

Crotty 2000A72 RCT but not relevant as trauma patients only (hip fracture)

Crotty 200374 RCT but not relevant as trauma patients only

Cunliffe 200276 Not RCT; qualitative study; abstract only

Dalal 200377 Not RCT; non-randomised prospective study




Daly 201378 Intervention incorrect. Set in outpatient setting

Deutsch 200681 Not RCT; retrospective study

Dey82 RCT; but unpublished data only. We have no access to paper and information in Cochrane review (Hospital at home early discharge) is insufficient to categorise the intervention

Dias 2013 84 RCT but not relevant (does not compare to inpatient rehabilitation)

Dickson 199985 Letter to the editor

DiMartino 86 2014 Not RCT; systematic review- screened for relevant references

Dolansky 201087 Not RCT

Dombi 200988 Not RCT; commentary on costs

Donaldson 198290 Not RCT; retrospective study

Donath 200191 Not RCT; Commentary

Donlevy 1996A92 Not relevant; article is on cross-training to provide care at home on discharge

Donnelly 200293 Included in community rehab review

Dorney-Smith 201194 Not RCT; case study of the cost of nurse-led hostels for the homeless

Dow 200495 Not RCT; case study

Dow 200796 Not RCT; qualitative study

Duffy 201097 RCT but wrong comparison (control group not in hospital)

Dyar 201298 Incorrect intervention. Only discussions of end of life

ECHEVARRIA201699 Systematic review- checked for relevant references

Eldar 2000A100 Not RCT; review

Elder 2001101 Not RCT; literature review

Emme 2014103 RCT; but no relevant outcomes

Emme 2014A104 RCT; but no relevant outcomes

Eron 2004105 Not RCT; no data

Feltner 2014106 Not RCT; systematic review

Fenton 1984107 Incorrect intervention- cost- effectiveness of home and hospital psychiatric treatment

Franklin 2012108 Not relevant intervention- multifactorial cardiac rehabilitation programme for MI patients. Study to be considered for community rehab review

Gaspoz 1994111 Not RCT; prospective cohort study

Ghanem 2010112 Not relevant intervention -home based pulmonary rehab programme for COPD. Study to be considered in community rehab review

GJELSVIK2014113 Study already included in the community rehab evidence review

Gladman 1994114 Not relevant intervention -follow-up of a controlled trial of domiciliary stroke rehabilitation (DOMINO Study). Study to be considered for community rehab review

Glasby 2008115 Not RCT; qualitative study

Glick 1998116 Not relevant – observing outcome of aneurysmal subarachnoid haemorrhage

Gobbi 2004117 Not RCT; and not relevant

Gracey 1992119 Not RCT; case studies

Graham 2013120 Not RCT; description of organisation of rehabilitation services

Grande 2004121 RCT on bereavement. Not relevant.




Graverholt 2014 122 Not RCT; review

Greer 2012123 Intervention incorrect and no outcomes that match protocol

Gregory 2010124 Not RCT; Cross-sectional study

Gregory 2009125 Not RCT; retrospective study

Griffiths 2000128 Not RCT; exploratory analyses

Griffiths 2005131 Not RCT; systematic review- screened for relevant references

Griffiths 2001127 RCT but not relevant comparison; both arms in-patient care (nurse led versus consultant managed)

Griffiths 2006A126 Not RCT; review

Griffiths 2006130 Not RCT; review

Griffiths 2000A129 RCT but not relevant comparison (in-patients only)

Gunnell 2000132 Not relevant; majority of patients with trauma and elective surgery

Hackett 2002133 Not relevant intervention -home based rehab for stroke patients. Study to be considered in community rehab review

Hamlet 2010134 Not RCT; uses secondary data. Focus is telemedicine

Hannan 2003135 Not RCT

Hansen 1992136 Incorrect intervention. The study evaluated a model for follow-up by home visits after discharge from hospital of persons aged 75 years or more.

Hardy 2001137 Not RCT; description of a service; and mainly trauma patients

Hansen 1992136 Cochrane excluded list: Hospital at home early discharge (study did not evaluate hospital at home, but a model for follow-up visits at home after discharge from hospital)

Hauser 1991139 Not RCT; retrospective study

Herr 2012143 Not RCT; retrospective study

Heseltine 2001144 Not RCT; review on cost

Hernandez 2015142 Not relevant intervention -community-based integrated care in frail COPD patients. Study included in the Integrated care review

Hill 1978146 RCT but not relevant to today’s approach of managing MI as thrombolytic therapy made admission necessary (Cochrane)

Hill 2013145 Incorrect intervention. The study aimed to evaluate the effect of providing tailored falls prevention education for older patients in hospital

Hofstad 2014147 Not relevant intervention. Study included in early supported discharge review

Hudson 2013148 Incorrect intervention; preparation of caregivers for home palliative acre with education and discussion

Hudson 2013149 Incorrect intervention; preparation of caregivers for home palliative acre with education and discussion

Hughes 1990150 RCT but has wrong comparison (not in hospital)

Hunger 2015151 Not relevant intervention- nurse based case management for aged myocardial infarction patients. Study to be considered in the nurse led review.

Huo 2014152 Not RCT; retrospective study. No outcomes of interest

Hwang 2013153 Not RCT; observational study. Large sample, but set in Taiwan

Indredavik 1999155 Included in community rehab review

Indredavik 2008156 RCT but no relevant outcomes

Jackson 2012157 Not relevant intervention -in-home, tele-rehabilitation programme for




intensive care unit survivors. Study to be considered in community rehab review

Jakobsen 2013158 Methodology of RCT only

Jolly 2005161 RCT but study aborted prematurely due to language barriers with participants. No data

Jones 1999162 Costs only

Jones 2014163 Not RCT; case study with little data

Kenny 2002166 Not RCT and not relevant

Kinley 2014167 Not RCT; retrospective observational study

Konrad 2012168 Not RCT; retrospective study

Koopman1996169 RCT but excluded as home care was self-administered

Kornowski 1995170 Not RCT; observational study

Kortke 2006171 Not RCT; open clinical study (non-randomised)

Korzeniowska-Kubacka 2014172 Not RCT; prospective observational study

Langhorne 2000174 Cochrane systematic review withdrawn from publication and superseded by Shepperd 2008271

Langhorne 2005175 Not RCT; review

Lappegard 2012176 Not RCT; retrospective study

Last 2000177 Not RCT, service description

Langhorne 2000174 Paper withdrawn from publication

Leon 2011179 RCT, but patient group and outcomes not relevant (stable HIV patients)

Leppert 2014180 Not RCT

Latour 2006178 Not relevant intervention. Study evaluated the impact of post-discharge, nurse-led, home-based case management intervention. Study to be considered in community nurse review

Lewis 2007182 Not RCT; commentary

Lewis 2011183 Not RCT; research protocol only

Lewis 2012185 Not RCT; commentary/conceptual paper

Lewis 2013184 Not RCT; case studies without data

Lewis 2013186 Not RCT; propensity matched controls study based on observational study data

Lim 2003187 RCT but not relevant comparison

Linertova 2011188 Not RCT; Systematic review- screened for relevant references

Leung 2015181 Incorrect study design- quasi experimental study (RCT evidence available)

Liu 2014189 Not relevant intervention-home-based pulmonary rehabilitation for patients with chronic obstructive pulmonary disease. Study to be considered for community rehab review.

Martin 1994190 Wrong comparison

Mason 2003191 Not RCT; description of a service

Mather 1976192 No description of the type of service patients at home received (excluded by Cochrane too)

Matukaitis 2005193 Not RCT. Pilot study and no comparison study

Mayhew 2006194 Not RCT; health economics only

Mayo 1998195 Conference abstract of study protocol only; duplicate of full paper Mayo 2000196

McKegney 1981197 No outcomes of interest




McNamee 1998198 Health economic evaluation

McWhinney 1994199 No outcome data reported. Authors describe the challenges of conducting a trail in this area

Melin 1992200 Not relevant: patients with long-term care needs were recruited. Hospital at Home was substitute for long-term care and not necessarily in-hospital

Melin 1993201 Cost evaluation

Meyer 2009203 Not RCT; case studies

Muijen 1992205 RCT but patients treated for acute, severe mental illness (psychiatric ward versus home); not relevant to AME guideline

Murphy 2005206 Not relevant intervention -home exercise programme immediately after hospitalisation for an exacerbation of COPD. Study to be considered in the community rehab review.

Mussi 2013207 Not relevant intervention-educative nursing intervention composed of home visits and phone calls. Study to be considered for inclusion in community nursing review

Nicholson 2001215 Health economics only

Nissen 2007217 Not in English (Danish)

Nordly 2014218 Protocol only; no study data

Nyatanga2014219 Not RCT; commentary/conceptual paper

Palmer Hill 2000224 Not relevant: patients recovering from knee replacement

Pandian2013226 Trial register only; no data

Pandian 2014227 Conference abstract

Patel 2004228 Health economic evaluation

Penque 1999230 Not RCT; retrospective study

Pittiglio 2011231 Not RCT; not relevant

Plochg 2005232 Not RCT; process evaluation

Pozzilli 2002233 RCT BUT not relevant (Multiple Sclerosis patients)

Prior2012 234 Not RCT

Puig-Junoy 2007235 Health economic evaluation

Qaddoura 2015236 Systematic review. Checked and ordered relevant references

Ram 2009237 Cochrane review- all 7 studies in the review have been included in our evidence review.

Raphael 2015238 Incorrect study design. Observational study (RCT evidence available)

Richards 1998 244 Not relevant; majority of patients with trauma and elective surgery

Richards 1998A243 Not relevant; correction to excluded trial with majority of patients with trauma and elective surgery

Richardson 2001 245 Health economic evaluation

Robinson 2009246 Not RCT; description of new model of acute care

Rodriguez-Cerrillo 2010248 Not RCT; Non-randomised prospective study

Rodriguez-Cerrillo 2012A247 Not RCT; no comparison group to home treatment

Round 2004250 Not RCT; prospective cohort study

Rosbotham-Williams 2002249 Not RCT; review

Rout 2011251 Not RCT; review

Rowley 1984252 Not RCT. No comparison group

Ruckley 1978253 Not relevant: patients following elective surgery




Rudkin 1997254 No service provided in community

Santana 2016255 Study considered for inclusion in the community rehab review

Sartain 2002256 Paediatric patient population

Saysell 2004257 Not RCT; pilot study of intermediate palliative care in care home

Schachter 2014258 Not RCT; study protocol only

Scheinberg 1986259 RCT but does not state what the control group intervention is

Schneller 2012260 Not RCT; case study

Schraibman 2001262 Incorrect intervention. Home versus in-patient treatment for deep vein thrombosis

Schou 2014261 RCT; but no relevant outcomes

Scott 2010263 Not RCT; literature review

Senaratne 1999264 Cost evaluation

Shepperd 2005270 Cochrane review updated in 2008 (Shepperd 2008 which is included in our evidence review)

Shepperd2016 274 Cochrane review- relevant references ordered

Subirana Serrate 2001283 Not RCT; health economics evaluation

Shepperd 1998269 Not RCT; systematic review

Shepperd 2005A266 Not RCT; editorial

Shepperd 2009A272 Not RCT; systematic review- screened for relevant references

Shepperd 1998A267 Costs only; no clinical outcomes

Sidebottom 2015275 In-patient care only considered. No alternative.

Sinclair 2005276 Not relevant intervention - home-based nurse intervention after suspected myocardial infarction. Study to be considered for community nursing review

Stephenson 1984278 Not RCT; conceptual paper

Steventon 2012279 Not RCT; retrospective analysis

Stewart 1999280 RCT but control group not in hospital.

Stromberg 2003282 RCT but only nurse-led follow up appointments in hospital. No actual community care given

Suijker 2012284 Protocol only; incorrect intervention

Suwanwela 2002285 RCT but not comparable to UK setting as home treatment was managed by Red Cross Volunteers and family members (Thailand)

Teng 2003287 Health economic evaluation

Tibaldi 2004295 RCT but no relevant outcomes (carer stress data incomplete)

Tistad 2015297 Non-RCT; observational

Thomas 1999290 conference abstract

Thorne 2001291 Not RCT; service description

Trappes-Lomax 2006298 RCT but comparison group not appropriate; did not receive ‘usual’ hospital care.

Upton 2014299 No RCT; not relevant

Utens 2010301 Study protocol of RCT only

Walshe 2010 308 Not RCT; review of qualitative papers

Wakefield 2008307 RCT but all self-care; wrong comparison

Widen Holmqvist 1996310 Health economic evaluation

Widen Holmqvist 1995309 Not RCT; observational study




Widen-Holmqvist 1998311 Superseded by Thorsen 2005293, 2006294 and Von Koch 2000306,2001305

Winkel 2008315 Not RCT; systematic review- screened for relevant references

Wolfe 2000316 RCT but excluded from Cochrane because intervention does not substitute for inpatient care; not valid comparison

Woodend 2008317 RCT but wrong control group; both at home with no actual care provided.

Woodhams 2012318 Not RCT; literature review

Young 2003B320 Not RCT; audit

Young 2005B321 Not RCT; quasi-experimental study

Young 2010B319 RCT but not relevant outcomes

Young 2010323 Incorrect intervention; not palliative

Ytterberg 2009324 conference abstract



Appendix H: Excluded economic studies

Table 14: Studies excluded from the economic review


Step-up/step-down

Armstrong 200817 This study was selectively excluded as it was a partial economic evaluation only looking at costs, based on non-randomised, non-UK evidence. Given that RCTs and UK evidence were included in the review it was felt more applicable evidence was available to inform the review.

Kameshwar 2016165 This study was selectively excluded as it was a partial economic evaluation only looking at costs, based on non-randomised non-UK evidence. Given that RCTs and UK evidence were included in the review it was felt more applicable evidence was available to inform the review.

O’Reilly 2006221 This study was assessed as partially applicable with minor limitations. However, given that a more applicable UK analysis by O’Reilly 2008220 was available, this study was selectively excluded.

Palmieri2013225 This study was selectively excluded as it was a partial economic evaluation only looking at costs, based on non-randomised non-UK evidence. Given that RCTs and UK evidence were included in the review it was felt more applicable evidence was available to inform the review.

Raphael 2005239 This study was assessed as partially applicable with very serious limitations. The study was a partial economic evaluation only looking at costs, based on non-randomised, observation evidence of a very small cohort of patients.

Virtual wards

Lewis 2013186 This study was assessed as partially applicable with serious limitations. The study is a case-control comparative costing study. QALYs were not used as an outcome and the follow-up was very short (6 months) and does not capture all the difference in costs. The intervention as defined by the study protocol was virtual wards, however, the authors report that after the initial pilot, the service delivered was actually case management rather than virtual wards, so it was difficult to ascertain the nature of the intervention. The comparator used for the controls was not clearly specified.

chapter 12 alternatives to hospital care - nice

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